PLEASE RETURN TO:
Immigration and Customs Enforcement
Freedom of Information Act Office
800 North Capitol Street, Suite 585
Washington, DC 20536
Via Fac
simile: (202) 732-0310
AFFIRMATION/DECLARATION
This is to affirm that
I, ____________________________________________________________________________,
(PRINT FULL NAME)
request access to records maintained by the U.S. 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)
Darya Ramos Hernandez
1234 Hilton Park Ave. Forks, Washington 09876
02/27/1982
El Salvador
Darya Ramos Hernandez
Darya Ramos Hernandez