Security Account Credit Card

*-*** (Rev. **-**-****) OMB-****-****

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 criminal 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 *First Name

Middle Name 1 Middle Name 2

*Date of Birth: *Place of Birth: *U.S. Citizen or Legal Permanent Resident:

Yes No

*Country of Citizenship: Country of Residence: Prisoner Number (if applicable):

*Last Four Digits of Social Security Number:

*Height: *Weight:

*Hair (please check appropriate box):

Bald Black Blonde/Strawberry Blue Brown Gray Green Orange Pink Purple Red/Auburn Sandy Unknown White

*Eyes (please check appropriate box):

Black Blue Brown Gray Green Hazel Maroon Multicolored Pink Unknown Applicant Home Address

*Address

*City *State

*Postal (Zip) Code *Country

Phone Number E-Mail

Mail Results to Address

C/O ATTN

Address

City State

Postal (Zip) Code Country

Phone Number (if different from above)

Payment Enclosed: (please check appropriate box)

CERTIFIED CHECK MONEY ORDER CREDIT CARD FORM

*Reason for Request:

Personal review Challenge information on your record Adoption of a child in the U.S. International adoption Live, work, or travel in a foreign country Other

* APPLICANT SIGNATURE 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. eForms

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