es/2i/2e1a 13:95 8035685739 SWANSEA TAX SERVICE PAGE 02/03
ut No. 163-095, Bees 11008
G-639, Freedom of Information/
Privacy Act Request
iy writen format for a Freedom of Information or Privacy Act reques is acceptable
‘NOTE: The completion ofthis form is optional.
START HERE Please type or print n black ink. Read instructions before completing thls form,
T. Type of request: (Check appropriate box.)
"Bd. Freedom of formation Act (FOIA) (Compare al tens except Number 6)
Evy APA) Midori be complete i ation ether pe wos)
Aon, Namber 5 rst be complete adton oi ohe appeals ens)
[5] Amendment. (P
T Requester information.
‘Name ofRequesten (las, Fastand Middle Nam) Sitesi [Devine Taepione
Simmons, Doris W 08-17-2010 103.568.5739
‘Address (Street Nimiber ane Name): P © Box 432 (290 W. Second Steet) ‘Apt. Numb
City: Swarica [owes sc Zip Code: 29160-0432
By ay sigantare;T consent tothe allowing?
ay all costs incurred for s fiction and review of materials upto $25.00, when applicable. (See Insirctions)
‘Signature of requester: Ov
Oy cecleed sujet Prot a death mast be tached (Obi, Dest Create rahe proof of death require)
SRT Tamron (Coupe Frame feet Rear) hemes Tard et compel)
3
Print Name of Person Giving Consent: “Signature of Person Giving Consent: (Original signature required.)
“By mip signature, I eonsent to the following: (Check applicable boxes)
[alow th Request nuedin Number 2 soretoseien: Allotmy sorts [1] porsion of my esas (prion sath
: eiow what partie. copy of application)
(Consort is required for recards of U. 8 citizens (USC) and Lenfil Permanent Residents (LPR).
TInformntion needed to search for record(s),
Sposli Hormation, documento) or Tesora) desea: (oy y name. date, subject mater and locaton of information,
‘All documentation regarding Rusol Water Grant obtained and approved for the Town of Swensee, SC
‘Documentation will include all requests and all disbursements spproved by USDA/Rural Developmen
--~ Purpose! (Optional: You are not required o sate the purpose of your request. However, doing s0.may assis USCIS 1 locate...
the records needed to respond to your request.)
& Data needed on subject of record. (ff daca marked with an asterisk (*) isnot provided, records may not be located)
+ Family Name: Given Name: ‘Middle Name:
7 Other names used, Hany F Name atime of oui io We US! TDa Adission
¥ Alion Registration Numiker: (AM) Petition or Cham Receipt | Country or Binh: [* Date of Binh Guy)
‘Harney of ther lily sembors tet may appear on requested records) (ke, Spouse, Daughter, Son):
FathersName Firs Miedle Last
Mothers Name First Wide Tast Gelade Maiden Name)
Fora G9 Rev TINO es/2i/2e1e 13:35 © ge3s6e5739 SWANSEA TAK SERVICE
Pace 93/23
i
[County of Origin: (Place of Departure)
Port-of Entry Into the U.S:
Date of Entry:
bce oT Ea (A, Sea, Lady
| Mode of Travel (Name of Carrter)
US. Sacial Security Number:
Namie on Naturalization Certiveate:
‘Canon
‘Naturalization Daler
"Adress on Date of Naturalization:
(Couit and Location:
] Verification of subject's identity: (See Instructions for explanation. Check one Bo)
DO invrerson with ID, (Cy Notarized Asfidavit of Identity
& Notary: (Normally needed fom persons
below)
[Other (Specify)
TelephoneNoz ( __)
crho are the subject afte record sought or for sworn declaration under penalty ef pern See
sgerbedandawer mtbefoe mets — [78 Dayot — fudusar- inde Yer 20)
sigrarrotNowy (2 ZA, My Commission Expireson _4~2- 20)
oR
NOTE: [0 detaration provided ini ofa notarised late, mt rata minima th following: Cnt Nery Seal or ton
in the appropriate space below)
Executed outside US.
‘Fexecuted outside the United States: "I declare (certify,
verify or state) under penalty of pegury under the laws of
the United States of America thet the foregoing is true and
correct
Signature:
(Seal/Stamp)
Executed in US.
Signature:
fexeouted within the United States, is territeries, possessions or
‘commoawealths I declare (certify, verify or state) under penalty
of perjury that the foregoing is true and correct.
(Seal/Stamp)
Fon 6-659 (Rav HVAMOO)Y Page?