13068 Walk-In Request for OPM Records or Information

OMB No. 3095-0037 Expires xx/xx/xxxx

WALK-IN REQUEST FOR OPM RECORDS OR INFORMATION CAUTION: Complete all items

NAME (print) LAST FIRST MIDDLE

SIGNATURE OF REQUESTER AND DATE OF REQUEST

     

     

     

SOCIAL SECURITY NUMBER

MAIL COPIES TO (Print)

     

NAME      

DATE OF BIRTH (mo., day, year)

STREET      

     

CITY      

STATE   

ZIP     

RECORD OF FEDERAL EMPLOYMENT

NAME EMPLOYED UNDER (if different from above)

AGENCY AND LOCATION

FROM

TO

     

     

     

     

     

     

     

     

     

     

     

     

INFORMATION AND/OR COPIES REQUESTED

     

PRIVACY ACT OF 1974 COMPLIANCE INFORMATION Authority for collection of the information is 44 U.S.C. 2907 and 3103 and Public Law 104-134 (April 26, 1996) as amended in title 31, section 7701. Disclosure of the information is voluntary. The principal purpose of the information is to assist the National Personnel Records Center in locating and verifying the correctness of the requested records or information to answer your inquiry. Routine uses of the information as established and published in accordance with 5 U.S.C. 552a(e)(4)(D) include the transfer of relevant information to appropriate federal, state, local, or foreign agencies for use in civil, criminal, or regulatory investigations or prosecution. In addition this form will be filed with the appropriate military or civilian records and may be transferred along with the record to another agency in accordance with the routine uses established by the agency which maintains the record. If the requested information is not provided, it may not be possible to service your inquiry. PAPERWORK REDUCTION ACT PUBLIC BURDEN STATEMENT An agency may not conduct or sponsor a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 3095-0037. The information requested on this form is being collected and used by the National Personnel Records Center to identify and locate civilian personnel records. Public burden reporting for this collection of information is estimated to be five minutes per response, including time for reviewing instructions and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to National Archives and Records Administration (NHP), 8601 Adelphi Road, College Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS. SEND COMPLETED FORMS TO THE ADDRESS SHOWN BELOW.

                       

Date:       ____________________________________ Archives Technician, NPRC Research Room NATIONAL PERSONNEL RECORDS CENTER (Research Room) 9700 Page Avenue St. Louis, MO 63132-5100

NATIONAL ARCHIVES AND RECORDS ADMINSTRATION NA FORM 13068 (REV. 9/09)