Privacy Act Notice Template - Us Army printable pdf download

Privacy Act Notice

The Army Donations Program office uses information that may be personal in nature to

qualify civilian organizations to receive United States Army property. This personal information

may include but is not limited to: name, social security number, driver’s license number,

taxpayer identification number, private telephone number (cell or home), private fax number,

e-mail address, home address, fingerprints, etc.

The disclosure of personal information is voluntary. Your organization may choose to

provide public information such as your building address, telephone number, fax number, etc. in

lieu of personal information with respect to qualifying or retaining government property. In the

event your organization decides to use personal information, each individual providing such data

is required to complete one of these forms. The individual should fill in the blanks at the bottom

of this document, sign the form, and return it to this office for placement in your file.

Personal information will only be used with respect to donation program requirements.

Personal information will not be disclosed, discussed, or shared with other individuals unless

they are directly involved in the donations process and have a direct need-to-know. Any

personal information that is provided will be safeguarded and protected to the best of our ability.

______________________________________________________________________________

I hereby request and authorize the donations office to collect, maintain, store, disseminate,

and use Personally Identifiable Information (PII) with respect to qualifying the undersigned

organization to receive and/or retain United States Army property.

ORGANIZATION______________________________________________________________

PRINTED NAME:______________________________________________________________

STREET ADDRESS:____________________________________________________________

CITY, STATE, ZIP CODE:_______________________________________________________

DATE:________________________________________________________________________

SIGNATURE:__________________________________________________________________

Mailing Address:

US Army TACOM Life Cycle Management Command, Attn: AMSTA-LCL-IWD,

M/S: 419D, 6501 East 11 Mile Road, Warren, MI 48397-5000

Privacy Act Notice Template - Us Army