Privacy Waiver and Certification of Identity
Complete, sign, and mail (original signature needed)
Privacy Waiver and Certification of Identity
Full Name: __________________________________________________________________________________________________________________________
Aliases used: ________________________________________________________________________________________________________________________
Current Address: _____________________________________________________________________________________________________________________
Date of Birth: ______________________ Place of Birth: _____________________________________________________________________________________
Social Security Number (optional): _______________________________________
(Optional: Prior addresses, employments, etc., which may assist the FBI in locating the requested information)
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____________________________________________________________ ______________________________________________________________________I hereby waive my right to privacy, and I authorize the FBI to release any and all information relating to me to:
(Name, address & phone of attorney or other designee)
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__________________________________________________________________________________________________________________________________Under penalty of perjury, I hereby declare that I am the person described above and 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: ___________________________________