Form ED-EVM.001.1 Perjury Form

UNITED STATES DEPARTMENT OF EDUCATION
OFFICE OF MANAGEMENT
Privacy, Information and Records Management Services
FORM APPROVED
OMB NO: 1880-XXXX Exp. XX/XX/XXXX

Certification of Identity and Consent

To ensure Privacy Act protected information is not released improperly, a request that is not made in person seeking access to records regarding you
or your minor child must be accompanied by verification(s) of identity. The Privacy Act requires that the requester provide us with original
signature(s) (not a copy or mechanical signature) when submitting this form to the Freedom of Information Act (FOIA) Service Center.
SECTION 1: REQUESTER INFORMATION
Subject's Full Name*1
Social Security Number*3

Request Number*2
Alternate Identification Number*4

Date of Birth

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 subject named
above or the parent or guardian of the minor subject named above. I understand that any falsification of this statement is punishable under the provisions
of 18 U.S.C. Section 1001 by a fine under that title or by imprisonment of not more than five years or both, and that requesting or obtaining any record(s)
under false pretenses is punishable under the provisions of 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000.

Date

Signature*5

If Applicable: Consent to release Privacy Act protected information to a third party.
Pursuant to 34 CFR Section 5b.9, I authorize the U.S. Department of Education and its contractors and agents to release the records indicated in
my Privacy Act request to the third party whom I have identified below.

Third Party: Print or Type Full Name
SECTION 2: CERTIFICATION OF IDENTITY OF ANY INDIVIDUAL THIRD PARTY
WITH CONSENT TO RECEIVE PRIVACY ACT PROTECTED INFORMATION
If the subject of the records (or the minor subject's parent or guardian) elected above to consent to release Privacy Act protected information to an
individual third party, then the individual third party will also be required to sign this section. As an individual third party, if you do not complete this
section of the form, the Department of Education and its contractors and agents will not provide you with the records as requested.
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 individual third
party named above. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine under that
title or by imprisonment of not more than five years or both, and that requesting or obtaining any record(s) under false pretenses is punishable under the
provisions of 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000.

Date

Signature*6
* Field Descriptions
1 Name of individual who is the subject of the record(s) being sought.
2 If it has been issued, provide the Department of Education Tracking Number for your related Privacy Act request.

3 Although providing your Social Security Number is voluntary, there are many types of records that the Department can locate only if the subject's Social Security Number has
been provided. You are asked to provide your Social Security Number to facilitate the identification of records relating to you or your minor child.
4 Although providing the Department with an Alternate Identification Number (e.g. your Debt # or an ID# issued to you by a Department Contractor or service provider) is
voluntary, the Department may need this Number in order to provide you with your requested records, particularly if you do not provide your Social Security Number.
5 Signature of individual who is the subject of the record(s) sought (or the minor subject's parent or guardian). In case of a parent or guardian, you must provide a copy of a birth
certificate, court order, tax return or other competent evidence of your relationship to the minor subject.
6 Signature of the individual third party to whom the subject (or the minor subject's parent or guardian) has consented to release the requested Privacy Act protected records.
Privacy Act Statement. In accordance with 34 CFR Section 5b.5(b)(2) personal data sufficient to identify the individuals submitting requests by mail under the Privacy Act of
1974, 5 U.S.C. Section 552a, is required. The purpose of this solicitation is to ensure that the records of individuals who are the subject of U.S. Department of Education systems
of records are not wrongfully disclosed by the Department. Requests will not be processed if this information is not furnished. False information on this form may subject the
requester to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control
number. The valid OMB control number for this information collection is 1880-XXXX. Public reporting burden for this collection of information is estimated to average 0.50
hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Obligation to respond is voluntary. If you have questions on your individual submission of this form, write directly to: FOIA Service Center, U.S.
Department of Education, 400 Maryland Avenue, S.W., Washington, D.C. 20202-4536.
ED-EMV-001.1 Exp. (XX/XX/XXXX)

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ED GRS 156, 157