Form OPM 1743 OPM 1743 OMBudsman - Third Party Authorization

OMB Approved: 3206-NEW

Expiration: MM/DD/YEAR

Page 2 of 2

U.S. Office of Personnel Management

Ombudsman - Third Party Authorization

Privacy Act Statement

5. U.S.C. 1103(a) allows for the collection of the information for the purpose of resolving issues of concern or complaints regarding an agency.  Information obtained will be used by the Ombudsman mainly to resolve issues of concern or complaints.  Other routine uses include law enforcement purposes, litigation, records management inspections, and congressional inquiries.  Providing this information is voluntary however, failure to furnish the requested information may delay or prevent the Ombudsman from assisting you with your request.

Public Burden Statement

The public reporting burden for this information collection is estimated to be 10 minutes. This burden estimate includes time for reviewing instructions, researching existing data sources, gathering and maintaining the needed data, and completing and submitting the information. Send comments regarding the accuracy of this burden estimate and any suggestions for reducing the burden to: U.S. Office of Personnel Management, Ombudsman, Attn: OMB Number (3206-NEW), 1900 E Street NW, Washington, DC 20415-7900.  You are not required to respond to this collection of information unless a valid OMB control number is displayed.

(Only complete if you want to designate someone in addition to, or other than yourself to give and receive information about your request for assistance to OPM)

Name _________________________________________________________________

Address _______________________________________________________________

City __________________________ State ______ Zip Code_________________

Home Phone (______) __________________ Work Phone (_____) _____________

Cell Phone (______) ______________ E-mail ________________________________

If you are a retired Federal employee, please provide us with your civil service (CSA,

CSF, or CSI, etc. ) number ____________________________________________________

What is the best way to contact you? ________________________________________

Designated Individual’s Name ____________________________________________

Relationship To You ____________________________________________________

Address _______________________________________________________________

City__________________________ State_____ Zip Code__________________

Home Phone (______) __________________ Work Phone (_____)______________

Cell Phone (______) ______________ E-mail ________________________________

Designee’s preferred method of contact ______________________________________

My signature below is my consent to allow representatives of the Ombudsman, Executive Secretariat and Ombudsman, U. S. Office of Personnel Management to obtain any information requested and to examine and/or copy any records related to my Request for Assistance submitted to the U.S. Office of Personnel Management. It also constitutes my consent to allow representatives of the OPM Ombudsman to communicate with my designee about my Request for Assistance.

In order to verify your identity, please provide a notarized signature, or, alternatively, an unsworn declaration in accordance with 28 U.S.C. 1746. (Please note: An unsworn statement replaces the need for a notarized signature)

U.S. Office of Personnel Management

Ombudsman - Third Party Authorization

• If executed within the United States, its territories, possessions, or commonwealths:

I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct,

Executed on:

____________________ ___________________________________

Date Signature

___________________________________ Printed Name

• If executed outside of the United States,

I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct.

Executed on:

____________________ ___________________________________

Date Signature

___________________________________

Printed Name

If you choose to provide a notarized release, please sign and have notarized below:

__________________________________ _______________________________

Name (printed) Signature

STATE OF________ :

COUNTY OF _______ :

On this _________ day of ________, 20__, before me, the undersigned notary public, personally appeared _________________, who proved to me through satisfactory evidence of identification, which was/were _____________________ to be the person whose name is signed on the preceding document in my presence.

_______________________ (official seal and signature of notary)

My commission expires:__________________________________

If you have had this Third Party Authorization notarized, please mail the original to the Ombudsman’s office at:

U.S. Office of Personnel Management

Ombudsman

Room 5450

1900 E Street, NW

Washington, DC 20415

If you are providing an unsworn declaration, you may either pdf or scan this form and e-mail it to [email protected] with your Request for Assistance or fax it to the Ombudsman at 202-606-0304.

OPM 1743

June 2010