Form DHS Form 590 DHS Form 590 Authorization to Release Information to Another Person

DHS Traveler Redress
Inquiry Program

Print Authorization
Authorization to Release
Information to Another Person

(DHS TRIP)

Authorization to Release Information to Another Person
Please complete this form to authorize DHS to disclose your personal information to another person.

My Information
You are asked to provide your information only to facilitate the identification and processing of your redress request. Without your information DHS may be unable to process your third party authorization request.

Name

Address

City

Country

State

Zip Code

Telephone

Pursuant to the Privacy Act of 1974 (5 U.S.C. § 552a(b)), I authorize the U.S. Department of Homeland
Security to release any and all information relating to my redress request to my representative.

My Representative's Information
Name

Address

City

Country

State

Zip Code

Telephone

Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury under the laws of the United
States of America that the foregoing is true and correct, and that 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 of not more than $10,000 or by imprisonment of not more than five years, or both.

My Signature:

Date:

Privacy Act Statement
Authority: Title IV of the Intelligence reform and Terrorism Prevention Act of 2004 authorizes DHS to take security measures to protect travel, and under Subtitle B, Section 4012(1)(G), the Act directs DHS to provide appeal and correction opportunities for travelers
whose information may be incorrect. Principal Purposes: DHS will use this information in order to assist you with seeking redress in connection with travel. Routine Uses: DHS will use and disclose this information to appropriate governmental agencies to verify
your identity, distinguish your identity from that of another individual, such as someone included on a watch list, and/or address your redress request. Additionally, limited information may be shared with non-governmental entities, such as air carriers, where
necessary for the sole purpose of carrying out your redress request. Disclosure: Furnishing this information is voluntary; however DHS may not be able to process your redress request without the information requested.
PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN:: Through this information collection, DHS is gathering information about you to conduct redress procedures, as an individual who believes he or she has been (1) denied or delayed boarding,
(2) denied or delayed entry into or departure from the United States as a port of entry, or (3) identified for additional screening at our Nation's transportation hubs, including airports, seaports, train stations and land borders. The public burden for this collection of
information is estimated to be five minutes. This is a voluntary collection of information. If you have any comments on this form, you may contact the Transportation Security Administration, Office of Transportation Security Redress, TSA-901, 601 S. 12th St.,
Arlington, VA 22202. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-NEW, which
expires dd/mm/yyyy.
FORM APPROVED OMB NO. 1652-NEW EXPIRES MM/DD/YYYY

DHS FORM 590 (02/07)