Fillable Privacy Act Request printable pdf download

PRIVACY ACT REQUEST FOR

Form Approved

OMB No. 3206-0266

COMPLETED STANDARD FORM SF85/SF85P/SF86

Instructions: Use of this form is optional. You may use any written format for a Freedom of Information (FOIA)

or Privacy Act (PA) Request as long as it contains a description of the information you are requesting and

sufficient personally identifying data when required. Failure to provide the required information may result in

no action being taken on the request. Submit completed forms via fax, mail, or e-mail as scanned attachments.

If submitting via e-mail, you should ensure that the security of your e-mail system is adequate for transmitting

sensitive information before choosing to transmit your request, which contains your personally identifiable

information. Mail: OPM-Federal Investigative Services; ATTN: FOI/PA office, 1137 Branchton Road, P.O. Box 618,

Boyers, PA 16018. e-Mail: FISStandardFormRequest@opm.gov.

1. Type of Request

- (This section must be completed.)

PA/FOIA Request: I request my most recent completed SF85, SF85P or SF86.

2. Requester Information

- (This section must be completed.)

Full Name:

Street Address:

City:

State:

Zip Code:

Country:

Preferred Delivery Method:

e-Mail Address:

Secure e-Mail*

Hardcopy Mail

Optional:

Telephone Number:

*A secure e-mail ensures that the information being sent to you is encrypted and therefore cannot be intercepted and read. Many widely used

e-mail providers accept this type of file. If your e-mail provider prohibits secure e-mails you will be notified to register with the OPM server.

This registration process will authenticate your identity and will allow the e-mail to be delivered directly to you.

3. Requester's Identifying Information

- (This section must be completed.)

Social Security Number:

Date of Birth: (MM/DD/YYYY)

City of Birth:

State of Birth:

Country of Birth:

4. Identity Source Documents -

(Copies of two identity source documents must be submitted along with this form.)

Examples of acceptable identity source documents are provided on the OPM-Federal Investigative Services FOIA/PA web page:

https://

Copies of two identity source documents are attached.

5. Verification of Requester's Identity

- (This section must be completed.)

I declare under the penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and I am the person

named in Section 2. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more

than $10,000, or by imprisonment for not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is

punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.

Handwritten Signature: _________________________________________________ Date:

INV 100A

U.S. Office of Personnel Management

Page 1 of 2

Sept 2015

Federal Investigative Services

Privacy Act Request

Related Articles

Related forms

Related Categories