SAMPLE FORM FOR PRIVACY ACT REQUESTS

[Dazeemay]

http://www.angelfire.com/mi/oaxamaxao/foia.html

Header should have complete names, addresses and telephone numbers of requester and the agency, organization, or person, receiving the Privacy Act Request.

TO: Name and complete address of Agency...............................FROM: Name of requester

PRIVACY ACT REQUEST

RE: REQUEST FOR NOTIFICATION AND ACCESS

1) This is a request under the Privacy Act, 5 USC 552a.

2. I understand the penalties provided in 5 USC 552a(i)(3) for requesting, or obtaining access to records, or information, under false pretenses.

3. If some of this request is exempt from release, please send me those portions reasoably separable and provide me with an itemization and justification, in writing, explaining the reasons for the exemptions and material, information, documents, and/or records that is not being released.

4. This is my firm promise to pay fees and costs for reviewing and duplicationg the records and documents requested.

5. This requester is requesting notification and access for copies of the following records:

(State the records or documents you are requesting as accurately as possible, avoid vague or general references to events or dates since the government need only respond to specific requests and need not reply to vague or general requests)

6. (State the reason your are requesting access to these records. I usually state to update and maintain my personal records, or to identify information that may not be complete, or accurate.) You can also state: "All records in which this requestor is a person named in a record, or report."YOU MUST STATE A REASON FOR REQUESTING ACCESS TO DOCUMENTS OR RECORDS.

7. Please respond within fourteen (14) business days upon receipt of this request. NOTE: Some states provide for shorter, or longer response times.

"I swear and affirm, under the penalties of perjury, that these representations are true, that I have personal knowledge of the facts stated herein, that I am competent to testify to the facts stated herein, and that this document is admissible in court as evidence."

DATED: __________________ ...............................SIGNED:______________________

.......................................................................................................(Your name and address here)

Subscribed and sworn to before me this____Day of____________1997

Notary of Public_______________________. My commission expires:______________.

Resident of________________________County, State of __________________________.

CERTIFICATE OF SERVICE

"I hereby certify that this PRIVACY ACT REQUEST was forwarded to (put name and address here) by certified US Mail, return receipt requested, on (date here). Certified US Mail Article Number: (usually Z or P ### ### ###)

DATED:____________________...........................................SIGNED:_____________________

This is a sample of a Privacy Act Request, some states may have statutes intended to comply with federal law of public access to records and documents, under the Privacy Act. It would be highly advisable to research these laws and modify the request to applicaple state stautes. This document is consistent with Federal Privacy Act Requests. The Privacy Act Request request is generally used for access to records of a more personal nature maintained by public agencies, such as the IRS, FBI, or many other law enforcement and administrative agencies.



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