F-2010-01500 INITIAL REQUEST

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 05562287
• Release Decision: RIPPUB
• Original Classification: U
• Document Page Count: 3
• Document Creation Date: March 9, 2023
• Document Release Date: December 8, 2021
• Case Number: F-2011-02160
• Publication Date: July 20, 2010

zu JUL. 19,2010..� 54114 MiAlOdfliII I
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0666
Central Intelligence Agency
Office of Public Affairs
Inforrietion and Privacy Coordinator
Delores Nelson
viaglinoton,D.C.20505
Phone: Ms) 4110623
Fain (7011)482.1/39
ofluly MAO
Dear Sirs
I am askIns your department to receive ill the applications previously done by any other
parson or organization, which have seeking Information about me under the freedom of
Informatkin Act (FOIA) regulations (see below) at your gamey.
I have a "budget" of $53, so please check with me before proceetengwith any request
g such Information about me.
TITLE 26.-JUDICIAL nerINZEITRAT:01;
Cute= te-onaluswors or sten=
PART 16-1PROOONTON OR rinleatra OF wonsitat, OR ZEPORM=7.011-.
Table Of Entente
Ounpare D_Proftett0A of Privacy and Acme, to Endividoal 'mend. Vadat
she Privacy Act of 1974
Sec. 16.47 teEmoseta tor an actbmnting cf record dtooloontrae.
(al Row made and addreceed. Except Wawa accountings of dinaleggree
(b)(6)
(b)(6)
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JkTUL. 19. 20101 r 5: 41(411 rtw'
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NO. 1(5 P.2
ore not required to be kept tea stated it paragraph (b) Of this
section), you may make n 010,10st for an accenting �f any dieelosurs
that has been made by the Department to another preen. organization, Cr
eTenoY of any regard about you. This eetountiag contains the date.
nature, and pureedt of each disclosure, as well au the name and Address
of the person, organisation. or Agency to which the clialleAure zaz Made.
Your regueSt for An accounting should identify **eh particular reCord it
;mention and ahould be made by writing directly to the Departmorit
component that 1044441A0 the record, follOoing the Preeeeoret is SIM
16.41.
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4JUL . 19.2010, 5:41AM A-tumid Si M. M.:dna (Mad J LILAS� NO.775 ' '" P. 3
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thg, Department efdastleo Casino
dond
Prism Act Statornem. In accordame with 24 ('FR keen l6.414 tsars{ do turns:ail its demi* the Individato Mown requeeti
by moil under the Pnvocy der ar 7I374. s u,sr. SKIM 55h, Is required The mom edits tolicitation is tar don the mom& of
mdisidoals who ore the tisbion or US Deportment of Junta systems of records am not wrengfidly discloned by the.Dganroom Pollute ro
furnish raw ntfortneneut will result in no ham being at an the roma Fels infbmottort at this (brit may emblem die rooms Co criM-
;nal Naha undor IS U.S C. Section 1001 water 51/.73 C. Section 512E131
Public reaming burden for Thu tellation of utformetton Is eirtmatod to avenge 0.5C hours pa roan. tholudin the filt0 ret MU'S"
ins I nstriXt10115, emarchirs 'Maims dad sources, gaddring and Worming 'he data raided, arld alaProling find fivkalla 4116 QIICiIQII
of infamianow Suggestion& for reducing talc burden nay be atibeitted to Dirmece, SIBS and AdrainimmtIve Serttem Neff, hence
Management Diviner, US, Depantrwin of Juadeo. Wortittgoarc DC 20510 and the Offla orinfermodert rind todPialarY Aram. DM=
of Mora:anent arid Budget, Public Lir Peron Project II t03-0416), Washington. DC 20503,
FuR Nkame of Rotel,.
Citizenship Sams
Current Add
Dale of Birth
I declare under penalty of perjury
person mimed ohm, end
bye fine of not T3ft
under Iblse pride
Signature 4 H
\ Social Security Number
-11.-m�����lIl��IP..I'�.Ii�qgp������O�Mag�o.
Piece of Birth
Leited Sags or Amalie thai the foregoing is tme end emit end am I am its
erre* turns is pont e *wee proeizons of IS US C. &ear irint
rm mere than five rare or both, and that neatoning or obtaining any meord(el
50 S.C. 552161(3) by slip. of not more thon $5,000.
Drat Clb Ithi5 4#5teq
OPTIONAL; Authorization to Release information to Another Person
1 hit horn Salto to be completed bye roamer who lit author1zin4 inkernetton Meditate himself or herself to be mimed to ember potion,
Father peat* to 5 USX* &Mien 552a(b). authorise the at Depeterent of hint to Were rely tre mil inkerretion reettesionn 03,
Print or Type Name
t Name of individtud who is the whied or the record sought.
I 'nem" StibMInnig ietta rotor the Privacy Au of 1974 must be either Wa clean of the United Stares or an Alien lawfully
0dm1ne4 101 permanent residence." ptheuant in S US C. Section 5524(10(2). Requests will be processed as Freedom of inthmenen Aci
rectums outworn po $ Li S.C. Section 532, rather km Privacy Aar rallied% lbr individuals who tiro not United Slams citizens or diem
Ion Nib admitted hit bemoan rendence
3 Providing your social scvuilly number is voluniory You am asked to prow* your mutt secatty number only to Mali= the
identification of record; rehiring in you Without ynur social teensy number. the Dworman may Octal:(a to Wad any at WI records
INMalftifts to ).au
4 Signmun: of individual ho tlw salvo of the record sought.
crninsi fall NU 114444t0
OM 4
I Mu Dutai)
411141
(b)(6)
(b)(6)
(b)(6)
(b)(6)
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