F-2010-00456 INITIAL REQUEST

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 05497658
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 4
• Document Creation Date: March 9, 2023
• Document Release Date: December 8, 2021
• Case Number: F-2011-02160
• Publication Date: January 12, 2010

Approved for Release: 2021/12/07 C05497658
F dog
FREEDOM OF INFORMATION ACT REQUEST
DATE: January 4 2010
C T AGENCY
OA/PRIVACY ACT
217505
RE: F.0 A. Request per 5 552 a
Dear F.0.1.4, Officer:
This is a specific request under the Freedom of Information Act, 5 U.S.C. 552a et seq.
I hereby request any and all records, documents, photographs, audio or video
recordings or any other type of information that your agency has in its possession that is in any
way connected to or related to, or even remotely in reference to the following:
*********SEE ATTACHED REQUEST***********
In the event that you believe that some or all of the requested information is exempt
from release, kindly advise me which exemptions you are relying on. Also please provide a
Vaughn index for all items withheld, as well as detailed justification for any exemptions
claimed, either specifically or implied.
As required by law, I anticipate a reply within ten (10) working days.
lf.there is a cost for the copying of this information, kindly contact me for authorization.
icnta
1,
accur Lang to
1
Place of Birth Ey. Birthdate
Social Security Number
DECLARATiON
hereby declare that the foregoing is true and correct
he best of my information) knowledge, and belief.
Dated this 4 day of January
2010
n atu
L.
Printed Name
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Approved for Release: 2021/12/07 C05497658
FOIA/Privacy Act/Open Records request
information sought.
All information which relates to, mentions, names, re
or otherwise in any way pertains to, singularly ok in
to if related to 3rd parties:
Heat he
If your office dete
d' 3
s that any part of this request is non-
eason, then please process any/all remaining
qPieptF:to_disolosure, either in part, or
at ;once,
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Certification of Identity
Pnvacy Act accowith 28 CFR Section 16.41(d) personal data sufficient to identify the individuals submitting
requests by mail under the Privacy Act of 1974, 5 USE. Section 552a, is required. The purpose of this solicitation is to ensure that the ck
records of individuals who are the subject of U.S. Department of Justice systems of records are not wrongfully disclosed by the
Department Failure to �innsn this information will result in no action being viz ten on the request . False information on this form may sub-
ject the requester to eHnunai penalties under 18 USE. Section 1001 and/or 5 US .C. Section 522a(i) (3).
Public reponing burden for this collection of infonhation is estimated to average 0 50 hours per response, rcluding the time for reviewing e
instrucdons, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
informailorti Suggestions for reducing this burden may be submitted to Director, Facilities and Administrative Services Staff, Justice
erneiitDivision, T.J.S. Department of Justice, Washington, DC 20530 and the Office of Inforrnntion and Regulatory Affairs, Office of
and Budget, Public Use Reports Project (11 03-0016), Washington, DC 20503,
Full Name of Requester
Current Address
Date of Birth
Place Birth
Social Security Number 2
I declare under penalty of perjury under the laws of the United States of America that the foregoing is mae and correct, and thai 1 am the
person Elated above, and I understand that any falsification of this statement is punihable under the provisions of 18 U.S.C. Section 1001
by a fine of not n of not more than five years or both, and that requesting or obtaining any record(s)
under false prefer ,of 5 U.S.C. 55:a(1)(3) by a fine of not more than S5,000.
Sign2Euric 3 .__
Dgc, 01/04/2010
Ogonech AuthothatCon to Release ulnbrriraitioai to Anothe
This form is also to be completed by a requester who is authorizing information relatin
person.
o nausea or TS'
be released to another
. .
Funher, pursuant to authorize the U.S. Department of Justice 10 release any and all information relating to me
(Pein' or "Type Name)
I Name of individual who is the subject of the record sought.
2 Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the identi-
fication of rnrconds relating to you. Without your social security number, the Department may be unable to locate any or all records pertain-
ing to you.
3 Signature of individual who is the subjeci of the record soughL.
FORM APPROVM OMB NO. 1103