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Affirmation Declaration

Declaration

Uploaded by

Veshaal Vinod Fondekar
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© © All Rights Reserved
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30 views1 page

Affirmation Declaration

Declaration

Uploaded by

Veshaal Vinod Fondekar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Freedom of Information Act Office

U.S. Department of Homeland Security


500 12th St SW, Stop 5009
Washington, DC 20536

AFFIRMATION/DECLARATION

This is to affirm that

I, ,
(PRINT FULL NAME)

request access to records maintained by the Immigration and Customs


Enforcement which pertain to me. My present address is:
,

my date of birth is: , and

my place of birth was: _.

I understand that any knowingly or willfully seeking or obtaining access to records about
another person under false pretenses is punishable by a fine of up to $5,000. I also
understand that any applicable fees must be paid by me.

I hereby authorize access to my records.


(PRINT FULL NAME)

I request that any located and disclosable records be forwarded to the following individual:

at the following address:


(PRINT FULL NAME)

I hereby declare or certify under penalty of perjury that the foregoing is true and correct.

Executed on
(DATE)

.
(SIGNATURE OF AFFIRMANT/DECLARANT).

PLEASE RETURN TO: U.S. Department of Homeland Security


Immigration and Customs Enforcement
500 12th Street, SW, Stop 5009, Washington, DC 20536-5009
Via Facsimile: 202-732-4265;
Via email: ice-foia@dhs.gov

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