Form 3975 Certificate of Identity

The public reporting burden mentioned on the original form implies that this is a public-use form, which if true normally would require an

_{OMB number & expiration date.}

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

_{Certification of Identity}

Form Approved: OMB No. xxxx-xxxx

Expiration Date: xx/xx/xxxx

(See Burden Statement below.)

Privacy Act Statement. In accordance with 28 CFR Section 16.41(d) 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 Food and Drug Administration systems of records are not wrongfully disclosed by the Agency. 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).

Full Name of Requestor ¹

_{Entry fields on many FDA forms are typically below the text label.}

Citizenship Status 2	Social Security Number 3 Designer note: This is a “layout design”
Current Address	Date of Birth proof. Entry fields will be added and the form will be made as a “508 compliant” and functional Adobe “LiveCycle” PDF
	Place of Birth file after FDA approves this layout design.

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, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine of not more than $10,000 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. 552a(i)(3) by a fine of not more than $5,000.

_Signature ⁴

_Date

On a form, ^{it is often} the case ^{that footnotes} come immediately

after the ^{section to} which they ^pertain. It is also ^{best to not}

stretch ^{several lines of} small type ^{across a full} page, due ^{to readability} issues. ^{So the width} here is ^{somewhat less.}

¹ Name of individual who is the subject of the record(s) sought.

² Individual submitting a request under the Privacy Act of 1974 must be either “a citizen of the United States or an alien lawfully admitted for permanent residence,” pursuant to 5 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C. Section 552, rather than Privacy Act requests, for individuals who are not United States citizens or aliens lawfully admitted for permanent residence.

³ Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the identification of records relating to you. Without your social security number, the Agency may be unable to locate any or all records pertaining to you.

⁴ _{Signature of individual who is the subject of the record sought.}

OPTIONAL: Authorization to Release Information to Another Person

This form is also to be completed by a requester who is authorizing information relating to himself or herself to be released to another person. Further, pursuant to 5 U.S.C. Section 552a(b), I authorize the U.S. Department of Justice to release any and all information relating to me to the person named below:

The FDA ^{PRA office requires the PRA section below to be placed on FDA public-use forms.}

_{The old OMB address} no longer ^{is placed in the section. The section is for the benefit of} form users ^{and pertains to the FDA PRA office, and it often is placed at the end of the form.}

_{Name of Person (Print or type)}

This section applies only to requirements of the Paperwork Reduction Act of 1995.

*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*

The burden time for this collection of information is estimated to average 0.5 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to the address below:

Department of Health and Human Services

Food and Drug Administration

Office of Operations

_{Paperwork Reduction Act (PRA) Staff}

“An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number.”

[email protected]

The “0.5 hours” amount above is the same amount of time as the “0.50 hours” on the old original we were given (both figures equal 30 minutes). Mathematically speaking it is not necessary to carry the

FORM FDA 3975 (5/16)

figure out to the hundredths instead of simply the tenths (one decimal position).

PSC Publishing Services (301) 443-6740 EF