AID 507-1 Freedom of Information/Privacy Act Record Request Form

OMB APPROVED

OMB NO. XXXX-XXXX

EXPIRES XX-XX-XX

FREEDOM OF INFORMATION / PRIVACY ACT RECORD REQUEST FORM

Instructions: Use of this form is optional. You may use any written format for a Freedom of Information (FOIA) or Privacy Act (PA) Request as long as it contains a description of the information you are requesting and sufficient personally identifying data when required. Failure to provide the required information may result in no action being taken on the request. Completed forms should be submitted by fax, mail, or e-mailed as scanned attachments. If submitting via e-mail, you should ensure that the security of your e-mail system is adequate for transmitting sensitive information before choosing to transmit your request which contains your personally identifiable information. Mail: U.S. Agency for International Development, M/MS/IRD, Suite 2.07C RRB, 1300 Pennsylvania Avenue NW, Washington, DC 20523-2701. Fax: 202-216-3070. E-Mail: [email protected].
Section 1. Type of Request – (This section must be completed.)
PA/FOIA Request: I request my own records. (Requester must complete sections 2, 3, 4, and 6.) FOIA Request: I am making a request for records about someone or something other than myself. (Requester must complete sections 2, 3, and 7.) PA Amendment Request: I wish to amend my own records. In accordance with 22 C.F.R. § 215.7, the burden of proof rests with the record subject to illustrate how his/her records are not accurate, timely, relevant, or complete. Requesters should attach additional material to this form. (Requester must complete sections 2, 4, and 6.)
Section 2. Requester Information – (This section must be completed.)
Full Name:      
Street Address:      
City:      	State:      	Zip Code:      	Country:      
Telephone Number:      		E-Mail Address:      
Section 3. Describe the type of information requested or the specific records, if known:
     

Section 4. Requester’s Identifying Information – (Complete this section only if you are making a request for records about yourself.)
Social Security Number:      			Date of Birth (MM/DD/YYYY):      
City of Birth:      		State:      			Country of Birth:      
Section 5. Optional: Authorization to Release Information to a Third Party
By completing this section, you authorize information relating to you to be released to another person, such as a family member or legal counsel. Pursuant to 5 U.S.C. § 552a(b), I authorize USAID to release my records (defined above) to:
Full Name:      
Mailing Address:      				E-mail Address:
Section 6. Proof of Identity
Acceptable sources include copies of 2 of the following source documents that must be notarized by a valid (non-expired) notary public. Check items enclosed with this request (Send copies only – do not send original documents.)
Proof of identity of requestor (and subject individual, if not requestor) is required from two sources.	Acceptable sources include copies of two of the following source documents that must be notarized by a valid (non-expired) notary public. Check items enclosed with this request: Unexpired U.S. Passport Social Security Card (both sides of card) Unexpired driver’s license or ID card issued by a state or outlying possession of the United States, provided it contains a photograph Certificate of U.S. Citizenship Certificate of Naturalization Permanent Resident Card Alien Registration Receipt Card with photograph U.S. Military card or draft record U.S. Military dependent’s ID Card
Under penalty of perjury, I hereby declare that I am the person named above and I understand any falsification of this statement is punishable under the provisions of Title 18, United States Code (U.S.C.), Section 1001 by a fine of not more than $10,000 or by imprisonment of note more than five years, or both; and that requesting or obtaining any record (s) under false pretenses is punishable under the provision of Title 5, U.S.C., Section 552a (i)(3) as a misdemeanor and by a fine of note more than $5,000.
Signature						Date      
Section 7. Complete this section only if you are requesting records about someone or something other than yourself
In the box below, you may wish to provide information about yourself and the purpose of your request to help us determine your fee category. While FOIA does not require a requestor to state the purpose of a request, fees may be reduced based on the nature of the requestor or purpose of the request. Fees for searching, copying, and processing records in this category may be levied in accordance with OPM’s regulations at 22 C.F.R. § 212.35. If you ask for a waiver or reduction of fees, you can also use this box to provide an explanation. Attach a separate page if you need more space than provided below.      
I agree to pay all applicable fees. I agree to pay up to a specific amount for fees. Specify:       I request a waiver or reduction of fees because I am (check all options listed below that apply): Affiliated with an educational or non-commercial scientific institution and this request is not for commercial use. A representative of the news media and this request is part of a news dissemination function and not for commercial use. Requesting the information in order to contribute significantly to the public understanding of the operations or activities of the government and I do not primarily have a commercial interest in the information.

Privacy Act Statement:

Information provided by a requester will be used to locate and provide the requester responsive records pursuant to the Freedom of Information Act (5 U.S.C. § 552), and/or the Privacy Act of 1974 (5 U.S.C. § 552a). Authority to collect this information is contained in 5 U.S.C. § 552, 5 U.S.C. § 552a, and 22 C.F.R. § 215.4. The purpose of the collection is to enable the U.S. Agency for International Development to locate applicable records and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Failure to provide the required information may result in no action being taken on the request.

Routine Use:

The routine use of this information is for identification purposes and to locate records associated with the requesting individual. Disclosure of this information is mandatory in order to correctly identify the records being requested.

Information Regarding Disclosure of your Social Security Number (SSN) under Public Law 93-579, Section 7 (b):

Solicitation of Social Security Numbers (SSNs) by USAID is authorized under the provision of Executive Order 9397, dated November 22, 1943. 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, USAID may be unable to locate records pertaining to you. The use of SSNs is necessary because of the large number of Federal employees, contractors, civilians, and military personnel who have identical names and/or birth date and whose identities can only be distinguished by their SSNs.

Public Burden Statement:

Public burden reporting for this collection of information is estimated to be an average of 9 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the accuracy of this burden estimation and any suggestions for reducing the burden to: U.S. Agency for International Development, 1300 Pennsylvania Avenue NW, Ronald Reagan Building, Suite 2.07C, Washington, DC 20523-2701.

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