Information Relating to Beneficiary of Private Bill
Legal Form Number | G-79A |
Section | U.S. Immigration and Customs Enforcement |
Issuer | U.S. Immigration and Customs Enforcement |
Full name and address of employer
Page 1 of 6
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
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 -
Date of birth Place of birth Citizenship (country)
Sex Complexion Height
ft.
Weight
lbs.
Eyes Hair Visible marks or scars
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
Type of work Month Year Month Year
$
United States Social Security Number
Show any other present income.
ICE Form G-79A (10/24)
PRIVATE BILL NO. FOR RELIEF OF
in.
Per
Present salary
Other names used (including maiden name)Naturalization Certificate Number
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