TO: Disclosure Officer FROM:

____________________ ____________________

____________________ ____________________



Dear Sir:


I. This is 5 USC 55 a request under the Privacy Act, 5 USC 552a, and the Freedom of Information Act, 5 USC 552. I am prepared to pay reasonable cost in locating the information listed below and reproducing it. My Social Security number is given below. If some of my request is exempt from release, please furnish me with the portions ?reasonably segregable." If you determine that some of my request is exempt, please provide me with an indexing, itemization and detailed justification concerning information, which you are not releasing.

2. I request that you send me a copy of any and all documents, records or materials about me, concerning me or mentioning me, located anywhere or in any systems of records in your agency. I specifically request that you search each and every file, system of files or system of records, in particular those pertaining to me, in your entire agency and those under your control, in particular those pertaining to me, for any item, collection or grouping of information pertaining to me and furnish that to me.


3. I request in particular the following documents:












4. Also, furnish me with an accounting of all agency disclosures pertaining to me or to records on me including the date, nature and purpose of each disclosure, and the person and agency to whom the disclosure was made. Privacy Act (c)


Date: ___________________ Yours,



SSN#: ____________________ Requestor_____________________



I declare under oath that I am the individual making this request, that I have furnished to the notary Public positive identification and that this is my signature.

Sworn to me this _____, day of _____20




Notary Public for this State


My commission expires: ______________________