This letter is intended to be sent to federal agencies to request specific documents about you personally.  It is not used to request public, nonpersonal information.  For Public information, use the Freedom of Information Act Request form instead.

Our thanks go to attorney Robert Clarkson (now deceased) for providing this form.

You should send your FOIA/Privacy Act  request to the address you locate on the following website:

http://www.irs.gov/prod/preview/foia/offices.html

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PRIVACY ACT REQUEST FOR DOCUMENTS

TO:

Disclosure Officer ____________________________ ____________________________ ____________________________ ____________________________

FROM:

____________________________ ____________________________ ____________________________ ____________________________

Dear Sir,

1.        This is a request under the Privacy Act, 5 U.S.C. 552a, and the Freedom of Information Act, 5 U.S.C. 552.  I am prepared to pay reasonable cost in locating the information listed below and reproducing it.  My Social Security Number (if any) is given below.  If some of my request is exempt from release, please furnish me with the portions “reasonably segregable.” If you determine that some of my request is exempt, please provide me with an indexing, itemization and detailed justification concerning information which you are not releasing.

2.        I request that you send me a copy of any and all documents, records or materials about me, concerning me or mentioning me, located anywhere or in any systems of records in your agency.  I specifically request that you search each and every file, system of files or system of records, in particular those pertaining to me, in your entire agency and those under your control, in particular those pertaining to me, for any item, collection or grouping of information pertaining to me and furnish that to me.

3.        I request in particular the following documents:

 

4.        Also, please furnish me with an accounting of all agency disclosures pertaining to me or to records on me including the date, nature and purpose of each disclosure, and the person and agency to whom the disclosure was made.  Privacy Act (c ).

Date: ______________________________                          Yours,

SSN#: _____________________________                            __________________________________

                                                              Requestor

I declare under oath that I am the individual making this request, that I have furnished to the notary public positive identification and that this is my signature.

Sworn to me this_____day of ______________, 20___

___________________________________________

Notary Public for this state

My commission expires on:_____________________               __________________________________

                                                             Requestor