P-2010-00472 SUPPLEMENTAL INFORMATION PROVIDED

• Document Type: FOIA
• Collection: FOIA Collection
• Document Number (FOIA) /ESDN (CREST): 05521382
• 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: April 14, 2010

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FREEDOM OF�INFORM, ON/
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(b)(6)
PURSUANT TO TITLE 5. UNITED STATES CODE, SECTIONS 552, 552(a), I THE UNDERSIGNED, IDENTIFIED
AS ABOVE, RESPECTFULLY REQUEST THE ACCESS TO, THE DISCLOSURE OF, THE RELEASE GE, AND
THE OPPORTUNITY TO CORRECT AND AMEND, THE FOLLOWING RECORDS MAINTAINED BY YOUR
AGENCY: (b)(6)
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I AM ALSO REQUESTING A COPY OF THE APP11
PROVIDED FOR BY THE FOE/PA, AS AMENDED PI
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BEE RULES
ATIONS FOR YOU
LAW 93-502. STAT. 15,53.
CENCI AS
IF FOR ANY REASON, ANY OF THE ABOVE-REQUESTED RECORDS ARE DEEMED TO BE NON-
DISCDOSABLE, 'OR NON-RELEASABLE, PLEASE SPECIFY THE REGULATORY & STATUTOFIS EXEMPTION
RELIED UPON, AND STATE 1/1/11FTHER THE ENTIRE DOCUMENT OR ONLY A PORTION THEREOF, E
DEEMED NON-DISCLOSABLE, AND FURNISH Am OF THE PERSON MAKIN, iFil
DECISION.
REQUESTER E AN IN' GENT INMATE AT
AND/OR DUPLICATIO S BE WAIVED
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(b)(6)
THE FOX/PA PROVIDES FOR A REPLY TO THIS REQUEST IN 'T.EN(PI) WORKING DAYS. REQUESTER
HEREBY INVOICES THIS PROVISION FOR A RESPONSE TO REQUEST WITHIN TEN (10) WORKING
DAYS. (b)(6)
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PRIVACY ACT STATEMENT:
individual submitting requests by
FULL NAME OF REQUES
ADDRESS:. _1
PLACE OF BIRTH]
EMPLOYEE NUMBER: \
In accordance with 23
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by a fine of not more
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Privacy Waiver and Certification of Identi
Full Name._
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Current Addre
Date of Birth
Social Security Numb (optiona
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Place of Birth:
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Under penalty of perjury, I hereby declare that I am the person described above and understand that any
falsification of this statement is punishable under the provisions of Title 18, United States Code (ISL.), Section
1001 by a fine of not more than $10,000 or by imprisonment of not more than five years, or both; and that
reques ing or obtaining any record(s) under false pretenses is punishable under the provisions of Title 5, U.S.C.,
Section 552a s a misdemeanor than $5,000
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Approved for Release: 2021/12/07 C05521382
(b)(6)
(b)(6)
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