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 by requiring Federal agencies...to permit and 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 in order that this individual may make a reasonable determination concerning divulgence of information to this agency.

1. Name of public servant______________________________ 

2. Residence __________ City __________ State __________ Zip__________

3. Name of department, bureau, or agency by which public servant
   is employed__________  Supervisor's name __________

4. It's mailing address__________ City __________ State __________  Zip__________

5. Will public servant uphold the Constitution of the United States?   __________ 

6. Did public servant furnish proof of identity?   __________ 

7. What was the nature of proof?____________________

8. Will public servant furnish a copy of the law or regulation which
   authorizes this investigation?  __________ 

9. Will the public servant read aloud the portion of the law authorizing
   the questions he will ask?  __________ 

10. Are the answers to the questions voluntary or mandatory?  __________ 

11. Are the questions to be asked based upon a specific law/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 not to answer
	any part or all of these questions?  __________ 

15. Name of person in government requesting that this investigation be
	made____________________

16. Is this investigation 'general' or is it 'special'?  __________ 

17. Have you consulted, questioned, interviewed, or received information
	from any third party relative to this investigation?  __________ 

18. If so, the identity of such third parties__________

19. Do you reasonably anticipate either a civil or criminal action to
	be initiated or pursued based upon any of the requested information? __________ 

20. Is there a file of records, information, or correspondence relating
	to me being maintained by this agency?  __________ 	If yes, which?  __________ 

21. Is this agency using any information pertaining to me which was
	supplied by another agency or government source? __________ 

22. May I have a copy of that information? __________ 

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? __________  If not, why not? __________ 
	 ______________________________________________________________________ 

	 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 swear (affirm) that the answers I have given to the foregoing
questions are complete and correct in every particular.

X ____________________________  Date: ________/_________/_____________

Witness:________________________   Witness:__________________________




Authorities for Questions:
1,2,3,4   In order to be sure you know exactly who you are giving the
	information to. Residence and business addresses are needed in case you
	need to serve process in a civil or criminal action upon this individual.
5		  All public servants have taken a sworn oath to uphold and
	defend the constitution.
6,7 	  This is standard procedure by government agents and officers.
	See Internal Revenue Manual, MT-9900-26, Section 242.133.
8,9,10	  Title 5 USC 552a, paragraph (e) (3) (A)
11		  Title 5 USC 552a, paragraph (d) (5), (e) (1)
12,13	  Title 5 USC 552a, paragraph (e) (3) (B), (e) (3) (C)
14		  Title 5 USC 552a, paragraph (e) (3) (D)
15		  Public Law 93-579 (b) (1)
16		  Title 5 USC 552a, paragraph (e) (3) (A)
17,18	  Title 5 USC 552a, paragraph (e) (2)
19		  Title 5 USC 552a, paragraph (d) (5)
20,21	  Public Law 93-579 (b) (1)
22		  Title 5 USC 552a, paragraph (d) (1)
23		  Title 5 USC 552a, paragraph (e) (10)

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