In order to provide you with the requested information, the following identity verification data is needed (In addition you must use one of the perjury statements listed below)
1.  Person name and phone number 
2.  Address 
3.  Relationship 
4.  Who the request is regarding (name of individual, if not yourself, or investigation) 
5.  SSN ((provide the SSN of the individual to whom the request is pertaining to is voluntary). It will be used to facilitate the identification of records. Without the SSN, we may be unable to locate the records requested) 
6.  Statement: Under the Freedom of Information Act/Privacy, I am requesting information regarding the above names individual or file. (If the information is in regards to a minor, are you're the legal guardian?) (Please provide additional information to support your request).

This statement is required if someone is asking for Privacy Act Information about themselves: 

Requester Name (printed) 

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above (requester) and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. section 1001 by a fine of not more than $10,000.00 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 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.00. 

Requester Signature and Date:
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This statement is required if someone is authorizing another person (Third Party) to receive Privacy Act Information about them: 

I Name (printed) authorize release of my information which is protected under the privacy act to: Name (printed)

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above (requester) and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. section 1001 by a fine of not more than $10,000.00 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 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.00.

Requester Signature and Date:

NOTE: For each of the statements above a signature is required (Do Not Print). mail the form. 
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