PRIVACY ACT
REQUEST FOR DOCUMENTS
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:
______________________
Requestor______________________