DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

INFORMATION RELATING TO BENEFICIARY OF PRIVATE BILL
OMB NO. 1653-0026
Expires: 10/31/2027
File Number

TO ASSIST U.S. IMMIGRATION AND CUSTOMS ENFORCEMENT IN MAKING ITS REPORT TO CONGRESS WITH RESPECT TO
PRIVATE BILL NO. FOR RELIEF OF
IN WHICH I AM THE BENEFICIARY INTERESTED PARTY, THE FOLLOWING INFORMATION IS FURNISHED.
Submit separate form for each beneficiary or interested party. If you need more space to answer fully any questions on this form, use a
separate sheet, identify each answer with the number of the corresponding question, and date and sign each sheet.

PLEASE TYPE OR PRINT.

1. PERSONAL DATA
Name (Last in caps) (First) (Middle) Alien Registration Number
A-
Other names used (including maiden name) Naturalization Certificate Number

Date of birth Place of birth Citizenship (country)

Sex Complexion Height Weight Eyes Hair Visible marks or scars

ft. in. lbs.
2. RESIDENCE DATA
List complete addresses, including zip code if possible, for past 10 years. (If additional space is needed, use a blank continuation page.)
From To
Street and Number City Province Country
Month Year Month Year

3. EDUCATIONAL DATA
Show name and location of last school attended including highest grade completed or degrees earned and date.

4. EMPLOYMENT DATA
Employment during past 5 years. (If additional space is needed, use a blank continuation page.)
From To
Full name and address of employer Type of work
Month Year Month Year

Present salary United States Social Security Number

$ Per
Show any other present income.

ICE Form G-79A (10/24) Page 1 of 6

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5. ASSETS AND LIABILITIES
List value of each asset and your equity in each, and show all debts. The value of all personal property may be shown as a single figure.

6. MARITAL DATA
Name of present spouse Address of present spouse

Date of birth of spouse Place of birth of spouse Citizenship of spouse

Date of marriage Place of marriage Present spouse depends on me for support

Yes No
Show the following for all previous marriages (Name of spouse, date and place of marriage, date and place marriage terminated and
how marriage was terminated)

7. DATA CONCERNING CHILDREN (If child depends on you for support, place an "X" before his or her name)
Name of child (Include address if not living with you) Date of birth Place of birth Citizenship

8. OTHER PERSONS DEPENDENT UPON ME FOR SUPPORT (Do not include children named in item 7 or present spouse)
Name Relationship Amount (Weekly or monthly)

9. DATA RELATING TO PARENTS

Father's name Address if living (If deceased, write "Deceased")

Date of birth Place of birth Citizenship

Mother's name Address if living (If deceased, write "Deceased")

Date of birth Place of birth Citizenship

10. SELECTIVE SERVICE DATA (If applicable)

Number and location of local board where registered Date registered Classification

11. MILITARY SERVICE DATA (If you are now serving or have ever served in the U.S. Armed Forces)
Branch of service Serial number Dates served
From To
If discharged, show type of discharge received (Honorable,
Present APO service address
dishonorable, etc.)

Rank at time of discharge

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12. DATA RELATING TO UNITED STATES ENTRIES AND DEPARTURES

Status at time of entry
Date of entry Port of entry Date of departure Port of departure
(Visitor, permanent resident, etc.)

13. DATA CONCERNING VISAS

a. If you were ever refused a visa by an American Consulate, fill in the following:
Location of Consulate Date visa refused

Reason for refusal

b. If you are the beneficiary of a Preference Immigrant Visa Petition fill in the following:
(Check one) A 1st 2nd 3rd 4th 5th 6th Preference Immigrant Visa Petition in my behalf was filed on:
Date filed Place filed Person who filed petition

c. Did you ever apply for Classification as a Conditional Entrant (7th Preference) Yes No
Date filed Place filed Was application approved
Yes No Date:
d. If you have ever registered with an American Consulate show the following:
Location of Consulate Date registered

14. LIST PRESENT AND PAST MEMBERSHIP IN ALL ORGANIZATIONS, CLUBS, ASSOCIATIONS, ETC.
Dates of membership
Name of organization Location
From To

15. IF YOU HAVE EVER BEEN ARRESTED ANYWHERE, SHOW THE FOLLOWING: (Include traffic violations)
Place arrested Date arrested Charge Disposition

16. IF YOU HAVE EVER BEEN HOSPITALIZED OR INSTITUTIONALIZED SHOW THE FOLLOWING:
Name and location of hospital or institution Dates Reason
From To

17. DATA CONCERNING NECESSITY FOR PRIVATE BILL

Show in this block any additional information concerning the beneficiary and/or concerning the necessity for a private bill in the
beneficiary's behalf (include any outstanding acts benefiting the United States or other friendly nations which would be of interest to
Congress)

ICE Form G-79A (10/24) Page 3 of 6

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18. OTHER DATA CONCERNING THIS CASE
Please include in this block any derogatory information concerning this case which you believe would aid the Congress in its
consideration of this bill. Also, if you wish this information to be treated in a confidential manner, please so state and give reason for
desiring such treatment.

19. DATA RELATING TO BENEFICIARY'S BROTHERS AND SISTERS (List all living brothers and sisters - include half or step
brothers and sisters)
Name Age Address Citizenship

20. DATA RELATING TO BENEFICIARY WHO HAS BEEN OR WILL BE ADOPTED

Name of child prior to adoption Date of adoption Place of adoption (Include court)

The adoption was by proxy with both adoptive parents present with one adoptive parent present.

The child's parents consented to the adoption No Yes Date consented

Name and addresses of child's living natural parents and step parents

Child lives with (include address) Child has resided with adoptive parents

Dates:
From To

21. DATA CONCERNING ANY PERSON IN THE UNITED STATES WHO COULD FURNISH ADDITIONAL INFORMATION
(State whether relative, or business or social acquaintance)
Name Relationship
Address
(Street and number) (City) (State) (Zip Code)

22. SIGNATURE OF BENEFICIARY OR INTERESTED PARTY

I hereby certify that the information given on this form is complete and true to the best of my knowledge and belief.

Date Signature (Sign in ink)

23. SIGNATURE OF PERSON PREPARING FORM, IF OTHER THAN BENEFICIARY OR INTERESTED PARTY
I declare that this document was prepared by me at the request of the beneficiary or interested party and is based on all information of
which I have any knowledge.

Signature (Sign in ink) Address Date

ICE Form G-79A (10/24) Page 4 of 6

Privacy Notice

Authority: The Immigration and Nationality Act (INA), as amended, (8 U.S.C. 1357) authorizes the collection of information
from any alien or person believed to be an alien as to his right to be or to remain in the United States. Sections 103 and 290
of the INA, as amended (8 U.S.C. 1103 and 1360), and the regulations issued pursuant thereto; and Section 451 of the
Homeland Security Act of 2002 (Pub. L. 107–296), codified at 6 U.S.C. 271 authorize the solicitation of the Social Security
Number (SSN).

Purpose: The purpose of gathering information is to assist the Judiciary Committee and Congress in determining whether
the immigration related private bill is necessary and whether the subject of the bill is worthy of the relief proposed. The SSN
will be used to verify employment, taxes paid, and any other assets attained while in the United States.

Agency Disclosure of Information: The information provided will be disclosed to the Judiciary Committee of either House
of Congress, which requires the information in order to hold hearings on and consider the merits of the immigration related
private bill. The information provided may also be disclosed to other federal agencies with appropriate jurisdiction,
authorities, and need-to-know in order to verify or ascertain information concerning the beneficiary of the private bill.
For United States Citizens, Lawful Permanent Residents, or individuals whose records are covered by the Judicial Redress
Act of 2015 (5 U.S.C. § 552a note), your information may be disclosed in accordance with the Privacy Act of 1974, 5 U.S.C.
§ 552a(b), including pursuant to the routine uses published in DHS/USCIS/ICE/CBP-001 - Alien File, Index, and National File
Tracking System of Records Notice, which can be viewed at www.dhs.gov/privacy.

Providing Information to DHS: Furnishing this information, including the SSN, is voluntary; however, failure to provide it
may result in the non-issuance of the desired immigration related benefit.

Public Reporting Burden. The U.S. Immigration and Customs Enforcement is collecting this information as a part of its
agency mission under the Department of Homeland Security. The estimated average time to review the instructions, search
existing data sources, gather and maintain the data needed and completing and reviewing this collection of information is 60
minutes (1.0 hours) per response. An agency may not conduct or sponsor, and a person is not required to respond to, an
information collection unless it displays a currently valid OMB Control Number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the
Department of Homeland Security, U.S. Immigration and Customs Enforcement, PRA Officer, 801 I Street NW, Washington,
D.C. 20536-5800 (Do not mail your completed application to this address.)

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 Continuation Page

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