Privacy Act - Certification Of Identity

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Central Intelligence Agency
Information and Privacy Coordinator
Washington, DC 20505 Fax (703)613-3007
PRIVACY ACT - CERTIFICATION OF IDENTITY
:
Privacy Act Statement
In accordance with 32 CFR Section 1901.13 personal data to identify the individual submitting requests by mail
or by electronic means under the Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The purpose of this form is to ensure that the records
of individuals are not wrongfully disclosed by Central Intelligence Agency (CIA). Requests will not be processed if all of this information is
not furnished. False information on this form may subject the requester to criminal penalties under 5 U.S.C. Section 552a(i)(3).
Your Full Name (Last, First, Middle) – Mr / Mrs / Ms: _______________________________________________________________
Any Other Names Used? ______________________________________________________________________________________
Your Current Mailing Address & Phone Number: ___________________________________________________________________
___________________________________________________________________________________________________________
Date of Birth: _________/______/________ Place of Birth (City and State): ____________________________________________
Month
Day
Year
1
CITIZENSHIP STATUS
(Please Check One)
2
_____US Citizen Social Security Number
_________-_______-___________ Other Country: ____________________________
OR
_____Naturalized Citizen as of _______/_______/__________ Naturalization #: ________________________________________
Month
Day
Year
OR
_____Permanent Resident Alien as of ________/_______/_________ PRA #___________________________________________
Month
Day
Year
Specific Records of Interest: ___________________________________________________________________________________
__________________________________________________________________________________________________________
OPTIONAL: Authorization to Release Information to Another Person: This section is to be completed by a
requester who is authorizing information relating to him/herself to be released to another person. Further, pursuant
to 5 U.S.C. 552a(b), I authorize the CIA to release any and all information relating to me to the following:
___________________________________________________________________________________________
Print name and address of person to whom records should be released
Statement Under Penalty of Perjury: I declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct, and that I am 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 pretenses is punishable under the provisions of
5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.
Your Signature: _________________________________________________ Date: ______________________________
1
Individual submitting a request under the Privacy Act of 1974 must be “a citizen of the United States or an alien lawfully admitted for permanent residence”, pursuant
to 5 U.S.C. 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C. 552, rather than Privacy Act requests, for individuals
who are not United States citizens or aliens lawfully admitted for permanent residence.
2
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, we may be unable to locate any or all records.
Form approved 13 June 2014

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