Pom Form 145 - Data Required By The Privacy Act Of 1974
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1REQUEST FOR FREEDOM OF INFORMATION ACT
DATA REQUIRED BY THE PRIVACY ACT OF 1974
Privacy Act Statement. Information provided by a requester will be used to locate and provide the requester responsive records pursuant to the Freedom of
Information Act (5 U.S.C. § 552), and/or the Privacy Act of 1974 (5 U.S.C. § 552a). Authority to collect this information is contained in 5 U.S.C. § 552, 5 U.S.C. §
552a, 5 C.F.R. § 297.201(b). The purpose of the collection is to enable the Department of the Army (DA) to locate applicable records and to respond to requests
made under the Freedom of Information Act (FOIA) and the Privacy Act of 1974.
Routine Uses. The information collected on this form will primarily be used to comply with requests for information under Title 5 U.S. Code 552 and 552a.
PLEASE READ INSTRUCTIONS BEFORE COMPLETING THE REQUEST
Use of this form is optional. You may use any written format for a Freedom of Information Act 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 mail, fax, or email as scanned attachments. If submitting via email, you should ensure that the security of your email system
is adequate for transmitting sensitive information before choosing to transmit your request, which contains your personally identifiable information. In accordance
with AR 25-55, The DA FOIA Program, soldiers and DA civilian employees, may as a private citizens, request records under the FOIA. They must prepare
requests at their own expense and time. They may not use Government equipment, supplies, or postage to prepare personal FOIA requests.
3. PHONE NUMBER (Cell)
1. REQUESTER'S FULL NAME (LAST, FIRST MI)
2. PHONE NUMBER (Home)
4. COMPLETE MAILING ADDRESS (Street Number, Street Name, City, State, Zip Code)
5. EMAIL ADDRESS (OPTIONAL)
6. Request that a copy of the following document(s) be provided to me. A detailed description of the desired record is provided to
enable the Government to locate the responsive record with a reasonable amount of effort.
7. In order to help you determine my category for the purpose of assessing fees, you should know that I am:
(please select one by clicking on the box):
An individual seeking information for a use or purpose that furthers my commercial, trade, or profit interest or the person on
whose behalf the request is made.
A representative of the news media and this request is made as part of news gathering and not for a commercial use.
Affiliated with an educational institution. This request is made for scholarly research and not for commercial use.
Affiliated with a non-commercial scientific institution. This request is made for scientific purpose and not for commercial use.
All other requesters (for those who do not fit any of the categories above).
8. Depending on my category in Item 7 above and to indicate my willingness to pay assessable search and duplication costs,
I am willing to pay fees for this request up to a maximum of $__________. If you estimate that the fees will exceed this limit,
please inform me first. I understand that I can request waiver of fees, but should also express a willingness to pay fees in the
event of a waiver denial.
9. Complete this section only if your are requesting a fee waiver. Be specific as this will determine approval of your
request for a fee waiver.
I am requesting a fee waiver because disclosure of the requested information to me is in the public interest and it is likely to
contribute significantly to the public understanding of the operations of the Army and is not primarily in my commercial interest.
The following details is how I intend to disseminate the requested information to the general public.
10. Verification of Requester's Identity.
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 above. I understand that any falsification of this statement is punishable under the
provisions of 18 U.S.C. § 1001 by a fine or by imprisonment or both. I understand 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.
SIGNATURE
DATE
Please send your completed and signed FOIA request:
1. via mail to:
U.S. Army Garrison, Presidio of Monterey, Attention: FOIA Officer, 393 Patton Avenue, Building 272,
Monterey, CA 93944, or
2. via fax to:
(831) 242-6979, or
3. via email to:
"usarmy.pom.106-sig-bde.mail.pres-asb@mail.mil"
POM Form 145, October 2015
Previous edition is obsolete
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