Public Law 93-579 states in part: "The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy requiring Federal agencies... to permit an individual to determine what records pertaining to him are collected, maintained, used or disseminated by such agencies...."

The following questions are based upon that act and are necessary for this individual to make a reasonable determination concerning divulgence of information to this agency.

1. Name of public servant ____________________________________________
2. Residence address _______________________________________________
City ___________________________________ State _________ Zip _________
3. Name of department of government, bureau, or agency by which public servant is employed. _________________________________________________________________
Supervisor's name _________________________________________________
4. Office mailing address:____________________________________________
City ____________________________________ State _________ Zip ________
5. Will public servant uphold the Constitution of the United States of America? Yes ______ No _______
6. Did public servant furnish proof of identity? Yes ______ No ______
7. What was the nature of proof? ID No. _____________________ Badge No. _________________
Driver's License No. ____________
8. Will public servant furnish a copy of the law or regulation which authorizes this investigation? Yes ____ No _____
9. Will the public servant read aloud that portion of the law authorizing the questions he will ask? Yes ___ No _____
10. Are the citizen's answers voluntary? _____ Or mandatory? _____
11. Are the questions to be asked based upon a specific law or regulation? ___________ or are they being used as a discovery process? ________
12. What other uses may be made of this information?
13. What other agencies may have access to this information?
14. What will be the effect upon me if I should choose to not answer any part of these questions?
15. Name of person in government requesting that this investigation be made? ________________________________
16. Is this investigation "general?" ____________ or is it "special?" _____________
Note: By "general" is meant any kind of blanket investigation in which a number of persons are involved because of geography, type of business, sex, religion, race, schooling, income, etc. By "special" is meant any investigation of an individual nature in which others are not involved.
17. Have you consulted, questioned, interviewed, or received information from any third party relative to this investigation? Yes ______ No ______
18. If yes, the identity of all such third parties? __________________________________________
19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information which you seek? Yes ______ No ______
20. Is there a file of records, information, or correspondence relating to me being maintained by this agency?
Yes ______ No _______
21. Is this agency using any information pertaining to me which was supplied by another agency or government source? Yes ______ No ______ If yes, which agencies and/or sources? ________________________________________
22. May I have a copy of that information? Yes ______ No ______
23. Will the public servant guarantee that the information in these files will not be used by any other department other than the one by whom he is employed? Yes ______ No ______
If any request for information relating to me is received from any person or agency, you must advise me in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided by the act.

I affirm that the answers I have given to the foregoing questions are complete and correct in every particular.
(Must be signed in ink and the signature should be witnessed by two people. Citizen may administer an oath if he/she so desires.)
Witness ____________________________________________________________
Witness ____________________________________________________________

* Based upon the Privacy Act of 1974