Freedom of Information / Privacy Act Request 

Requester Date of Birth: ________________

Registration Number: __________________________________ 

Place of Birth: __________________________

Address: __________________________________ 

Social Security Number: _______ - ____ - ___________

Agency Requested From: ________________ 

Case Number: ___________________________

District Court: _________________________ 

Pursuant to the Freedom Of Information Act, 5 USC 552, and the Privacy Act of 1974, 5 USC 552a, I hereby request copies of the following documents. If for any reason you chose not to send me any of the documents or papers requested then please furnish me with a "Vaughn Index" as set forth in Vaughn v. Rosen, 484 F2d 82O(D.C.D.C. 1973).

I am requesting all records, documents, and information you have in your files pertaining to me or mentioning my name.

Please consider this as a first-party request under the FOIA, 5 USC 552, and as a Privacy Act request, 5 USC 552a also.

In the event that some of the material is considered by you to be exempt from disclosure under both Acts, then please include all segregable portions of documents and the specific exemption you are relying upon to deny disclosure of the excised portions. Please note that in order to avoid disclosure you must claim an appropriate exemption under both Acts. 

I am requesting that you abide by the statutory time within which to make a determination on this request, that being ten(10) working days from your receipt under Section 552(a) (6)(A)(i).

I request a fee waiver or at least a fee reduction; however, in the event you deny this request for waiver I hereby agree to pay the fees for search and duplication while retaining my right to appeal your denial of waiver. The information requested will not be used for any commercial purpose.

I _____________________________________ hereby swear under the penalty of perjury that I am requesting all the above information and documents for my personal use.

Dated: ____________________________ 

State Of: __________________________

County Of: ________________________

Before Me, A Notary Public, on this day personally appeared known to me to be the person whose name is subscribed above and, being by me first duly sworn, declared that the information above is true and correct.

Given under my hand and seal of office this___________ day of ____________   ,

19 _____  .

Notary Public: ______________ 

My commission expires: ____________