CUSTOMS AM) BORDER PROTECTION DEPARTMENT OF HOMELAND SECURITY In accordance with the requirements of the Privacy Act of 1974 (5 U.S.C. § 522a) and Department of Homeland Security Privacy Act Regulations (6 C.F.R. §§ 5.21 (d) and 5.21(t)), the undersigned: Name: Social Security Number: Date of Birth: Place of Birth: Address: Jeffraaitein Janua