Privacy Act Request
The following information is necessary to file a Privacy Act request for
your records. Note: You or your agent may request records ONLY
about yourself. We will not process Privacy Act requests for records
about someone else, e.g., information about your spouse, your adult
child, your employee, etc.
Full Name:__________________________________________________________________
Aliases or other names used (e.g. maiden name):___________________________________
Current Address:
__________________________________________________________________________
____________________
______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Date of Birth: ___________________ Place of Birth:________________________________
Daytime Telephone Number: __________________
________________________________
Email address: _____________________________________________________________
Social Security Number: ____________
_________________________________________
(Optional - without it, we may not be able to locate all of your records)
Describe the record(s) you seek with enough detail that they may be located with
a
reasonable amount of effort:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
You may also wish to provide prior addresses, employments, etc., which you believe may
assist us in locating the information you seek:
__________________________________________________________________________
___________________
_______________________________________________________
__________________________________________________________________________
__________________________________________________________________________
I understand that any falsification of this statement is punishable under
the provisions
of Title 18, United States Code (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 Title 5, U.S.C.,
Section 552a(i)(3) as a misdemeanor and by a fine of not more than $5,000.
Signature ________________________
____________________ Date_______________
A legible and original signature and a legible copy of a government-issued
identification card is required. Legal representatives must additionally
present an original of proof of legal representation.
*Complete, Print, Sign and Mail Original of this Form*
******* YOU MUST PROVIDE A LEGIBLE COPY OF A
GOVERNMENT ID AND YOU MUST SIGN AND DATE THIS FORM. YOU
MAY MAIL, FAX OR E-MAIL THE FORM AND YOUR ID.
