AUTHORIZATION FOR THE RELEASE OF INFORMATION UNDER THE PRIVACY ACT
In accordance with the Privacy Act (PL 93-579) passed by Congress in 1974, a U.S. Consular Office cannot
release any information regarding you to anyone without your written consent except as set forth in the Act. Please
complete the authorization below, specifying whom a U.S. Consular Office may contact and to whom to release
information with regard to your case. Please return the completed authorization to a U.S. Consular Office. Local
language translations are acceptable to facilitate completion of the form in English.
U.S. Department of State
Place of Birth
I hereby authorize the U.S. Consular Office of the United States of America and the U.S. Department of State
to release information regarding me to the following individuals :
SECTION A
The U.S. Government, by providing the Authorization for the Release of Information Under the Privacy Act
Form, cannot under any circumstances compel an individual to complete and submit the form. PLEASE
CAREFULLY CONSIDER TO WHOM, AND WHAT INFORMATION IS BEING DISCLOSED.
IMPORTANT: You are not obliged to grant anyone access to information regarding you but failure to
provide the information requested on this form may make it more difficult, or impossible, for the
Department of State or the U.S. Consular Office to assist you.
DS-5505
06-2015
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Born At:
On:
Date of Birth
CONSULAR OFFICES OF THE UNITED STATES OF AMERICA
Name
Name
Name
Name
Name
Telephone
Number
Telephone
Number
Telephone
Number
Telephone
Number
Telephone
Number
Address
Address
Address
Address
Address
Relationship
Relationship
Relationship
Relationship
Relationship
Your Full Name (Last, First, MI)
(City, State/Province, Country)
(mm-dd-yyyy)
(Last, First)
(Last, First)
(Last, First)
(Last, First)
(Last, First)