Complete, print, sign, notarize, and mail form

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:
________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
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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.