Complete, print, sign, notarize, and mail form
Privacy Act Request
The following information is necessary in order to file a Freedom of Information-Privacy Acts (FOIPA) request.
Full Name: _______________________________________________________________________________________________________________________
Aliases used: _____________________________________________________________________________________________________________________
Current Address: __________________________________________________________________________________________________________________
Date of Birth: ___________________ Place of Birth: _____________________________________________________________________________________
Daytime Telephone Number: ______________________________________________
Social Security Number (optional): _________________________________________
You may also wish to provide prior addresses, employments, etc., which you believe may assist the FBI in locating the information you seek:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________Under penalty of perjury, I hereby declare that I am the person named above and 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 ________________________________
Please note that mail addressed to the FBI is delayed several weeks due to increased security procedures now in place.
A Legible and original signature is required.