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Get omb 1110 2014-2024

I-783 Rev. 7-1-2013 OMB-1110-0052 PRIVACY ACT STATEMENT The FBI s acquisition retention and sharing of information submitted on this form is generally authorized under 28 USC 534 and 28 CFR 16. 30-16. 34. The purpose for requesting this information from you is to provide the FBI with a minimum of identifying data to permit an accurate and timely search of identity history identification records. Providing this information including your Social Security Account Number is voluntary however failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent and may also be disclosed by the FBI without your consent pursuant to the Privacy Act of 1974 and all applicable routine uses. Under the Paperwork Reduction Act you are not required to complete this form unless it contains a valid OMB control number. The form takes approximately 3 minutes to complete. Applicant Information Denotes Required Fields Last Name Middle Name 1 Place of Birth Date of Birth Country of Citizenship First Name U*S* Citizen or Legal Permanent Resident Yes No Country of Residence Prisoner Number if applicable Last Four Digits of Social Security Number Height Hair please check appropriate box Bald Purple Black Blonde/Strawberry Red/Auburn Sandy Blue Unknown Brown Gray White Green Orange Pink Eyes please check appropriate box Hazel Maroon Multicolored Applicant Home Address Address City Postal Zip Code Phone Number State Country E-Mail Mail Results to Address C/O ATTN Payment Enclosed please check appropriate box CERTIFIED CHECK MONEY ORDER Reason for Request Personal review International adoption CREDIT CARD FORM Challenge information on your record Live work or travel in a foreign country APPLICANT SIGNATURE Adoption of a child in the U*S* Other DATE Mail the signed applicant information form fingerprint card and payment of 18 U*S* dollars to the following address FBI CJIS Division Summary Request 1000 Custer Hollow Road Clarksburg West Virginia 26306 You may request a copy of your own Identity History Summary to review it or obtain a change correction or an update to the summary. 30-16. 34. The purpose for requesting this information from you is to provide the FBI with a minimum of identifying data to permit an accurate and timely search of identity history identification records. Providing this information including your Social Security Account Number is voluntary however failure to provide the information may affect the completion of your request. Providing this information including your Social Security Account Number is voluntary however failure to provide the information may affect the completion of your request. The information reported on this form may be disclosed pursuant to your consent and may also be disclosed by the FBI without your consent pursuant to the Privacy Act of 1974 and all applicable routine uses. The information reported on this form may be disclosed pursuant to your consent and may also be disclosed by the FBI without your consent pursuant to the Privacy Act of 1974 and all applicable routine uses. Under the Paperwork Reduction Act you are not required to complete this form unless it contains a valid OMB control number. .

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