P-2010-01082 INITIAL REQUEST

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 05581744
• 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: September 9, 2010

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Pursuant to both the Freedom of Information Act, 5 U.S.C.� 552, and the Privacy Act, 5 U.S.0 � 552a, I
seek access to and copies of all records about me which you have in your possession.
To assist with your search for these records, I am providing the following additional information about
myself: full name, Social Security number, date of birth
If you determine that any portions of these documents are exempt under either of these statutes, I will
expect you to release the non-exempt portions to me as the law requires. I reserve the right to appeal
any decision to withhold information.
If my request is denied in whole or part, I ask that you justify all deletions by reference to specific
exemptions of the act.
I request a waiver of all fees for this request. Disclosure of the requested information to me is in the
public interest because it is likely to contribute significantly to public understanding of the operations or
activities of the government and is not primarily in my commercial interest.
Thank you for your assistance.
Sincerely,
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ILS. Department of Justice
Certification of Ide t
Privacy Act Statement In accordance with 28 CFR Section 16.41(d) per.onal data sufficient to identify the individuals submitting requests
by mail under the Privacy Act of t974,5 U.S.C. Section 552a, is required. The purpose of this solicitation is to ensure that the records of
individuals who arc the subject of U.S. Department of Justice systems of records are not wrongfully disclosed by the Department Failure to
furnish this information will result in no action being taken on the request. False information on this form may subject the requester to crim-
inal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).
Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for
revs w-
np instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
or information. Suggestions for reducing this burden may be submitted to Director, Facilities and Administrative Services Staff, Justice
Management Division, U.S. Department of Justice, Washington, DC 20530 and the Office of Information and Regulatory Affairs, Office
of Management and Budget, Public Use Reports Project (1103-00.16), Washington, DC 20503. (b)(6)
Full Name of Requester
Citizenship Status
Current Address
Date of Birtt
Social Security Mum
Place of Birth
I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that tarn the
person named above, 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 or by imprisonment of not more than five years or both, and that requesting or obtaining any record(s)
under false prfo^, ' C. 552a0)(3) by a tine of not more than $5,000.
Signature 4
OPTIONAL: Authorization to Release Information to Another Person
This form is also to be completed by a requester who is authorizing information relating to himsel
d to another person.
Further, pursuant to 5 U.S.C. Section 552a(b), I authotize the U.S. Department of Justice to release any and all information relating to me to:
Print or Type Name
I Name of individual who is the subject of the record sought.
2 Individual submitting a request under the Privacy Act of 1974 must be either "a citizen of the United States or an alien lawfully
admitted for permanent residence," pursuant to 5 U.S.C. Section 551(a)(2). Requests will be processed as Freedom of Information Act
requests pursuant to 5 U.S.C. Section 552, rather than Privacy Act requests, for individuals who are not United States citizens or aliens
lawfully admitted for permanent residence.
3 Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the
identification of records relating to you. Without your social security number, the Department may be unable to locate any or all records
pertaining to you.
4 Signature of individtial who is the subject of the record sought.
FORM APPROVED OMB NO. 1103-0016
EXPIRES 4131/07
FORM
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