OPTIONAL: Authorization to Release Information to Another Person
This form is also to be completed by a requester who is authorizing information relating to himself or herself to be released to another person.
Further, pursuant to 5 U.S.C. Section 552a(b), I authorize the U.S. Department of Justice to release any and all information relating to me to:
Print or Type Name
Signature
4
Date
Full Name of Requester
1
Citizenship Status
2
Social Security Number
3
Current Address
Date of Birth Place of Birth
U.S. Department of Justice
Certification of Identity
Privacy Act Statement. In accordance with 28 CFR Section 16.41(d) personal data sufficient to identify the individuals submitting requests
by mail under the Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The purpose of this solicitation is to ensure that the records of
individuals who are the subject of U.S. Department of Justice systems of records are not wrongfully disclosed by the Department. Failure to
furnish this information will result in no action being taken on the request. False information on this form may subject the requester to crim-
inal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).
Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for review-
ing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Suggestions for reducing this burden may be submitted to Director, Facilities and Administrative Services Staff, Justice
Management Division, U.S. Department of Justice, Washington, DC 20530 and the Office of Information and Regulatory Affairs, Office
of Management and Budget, Public Use Reports Project (1103-0016), Washington, DC 20503.
I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the
person named above, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001
by a fine of not more than $10,000 or by imprisonment of not more than five years or both, and that requesting or obtaining any record(s)
under false pretenses is punishable under the provisions of 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.
1
Name of individual who is the subject of the record sought.
2
Individual submitting a request under the Privacy Act of 1974 must be either “a citizen of the United States or an alien lawfully
admitted for permanent residence,” pursuant to 5 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom of Information Act
requests pursuant to 5 U.S.C. Section 552, rather than Privacy Act requests, for individuals who are not United States citizens or aliens
lawfully admitted for permanent residence.
3
Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the
identification of records relating to you. Without your social security number, the Department may be unable to locate any or all records
pertaining to you.
4
Signature of individual who is the subject of the record sought.
FORM APPROVED OMB NO. 1103-0016
EXPIRES 4/31/07
FORM DOJ-361
SEPT 04
