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: 07/31/2022

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 (3/19)

PRIVATE BILL NO. FOR RELIEF OF

in.

Per

Present salary

Other names used (including maiden name) Naturalization Certificate Number