To:______________________________

_______________________________

_______________________________

This letter constitutes my formal request for information pursuant to the provisions of the Freedom of Information and Privacy Acts, 5 USC 552.

I am requesting copies of all information maintained by your agency that pertain to myself as described below:

Full Name: ____________________________________________________________

Current Address: ______________________________________________________

Social Security No.: _____________________

Date and Place of Birth: ___________________________________________________

Former Addresses (use reverse if more space needed):

Date:____________ Signature:__________________________

I, __________________________ a Notary Public in and for the county (city) and state of __________________________ hereby certify that on the ____ day of _______, 19__, before me personally appeared __________________________, who is known by me to be the identical person whose name is subscribed to, and who signed and executed the foregoing instrument. In witness thereof, I have hereunto set my hand and official seal this day and year above.

My commission expires: ____________

Signature of Notary ________________________________________________

Printed: _________________________________________

Notary Seal:___________________

To find out if you have an FBI (or any federal agency) file and obtain a copy of it, fill out the above information, have this form notarized (you must sign it in front of a notary and provide the notary sufficient identification), and mail to the FBI (or other agency). A request should be sent to each field office that might have files as well as FBI Headquarters. Make a copy of your signed and notarized form for your records. Please note that it is a criminal offense to represent yourself as another in attempt of obtaining information.

THIS FORM IS A PUBLIC SERVICE OF GLEN L. ROBERTS
[HTML VERSION BY RJ]

You are encouraged to copy this form and distribute to others. Glen L. Roberts is editor of Full Disclosure. Glen L. Roberts, PO Box 1533, Oil City, PA 16301. Email: glr@ripco.com.
Web: http://pages.ripco.com:8080/~glr/glr.html

[For more help get FREE FOIA-Ware!] and here are all the mailing addresses you need

---

PURSUE | JUSTICE | VOTE | PEACE | DEFEND | RIGHTS | LEARN | LAW

---

---

Caveat

Go to the Self Help Legal Clinic Liberty's Educational Advocacy Forum Indiana's Fully Informed Jury Association, Inc.