Form 507-1 Certification of Identity

OMB APPROVED

OMB NO. XXXX-XXXX

EXPIRES: MM-DD-YYYY

CERTIFICATION OF IDENTITY

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: 1) a description of the information you are requesting; and 2) sufficient personally identifying data, when required. Without this required information, USAID cannot process your 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. If submitting via e-mail, for security reasons encrypt the message with the completed form, and use the same email address to send a password in a separate email message. 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: Requester Information – (Name of individual who is the subject of the record(s) sought.)
Full Name (Last, First, MI):      			Date of Birth (MM/DD/YYYY):      
Full Name of Subject of Records:      			Citizenship Status1:      
Current Address:       State:      			Country of Birth:       Country:      
Telephone Number:      			E-Mail Address:      
SECTION 2: Proof of Identity
Acceptable sources include copies of two (2) of the following source documents. Check items enclosed with this request (Send copies only – do not send original documents.)
Proof of Identity	Unexpired U.S. Passport Unexpired driver’s license or ID card issued by a state or outlying possession of the U.S., provided it contains a photograph 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 Death certificate/News article of death
SECTION 3: Authorization to Release Information to a Third Party – (Complete this section if you are authorizing release of your records to another person.)
Pursuant to 5 U.S.C. § 552a(b), I authorize USAID to release the requested records to: Full Name of Third Party:      
Mailing Address of Third Party:      		E-mail Address:      
Type of Third Party (Check one): Parent Custodial Guardian Legal Representation Other      
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 also understand that 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.
Signature2:      				Date (MM/DD/YYYY):      

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. § 212, Subpart M. The purpose of this 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.

Public Burden Statement:

Public burden reporting for this collection of information is estimated to be an average of nine (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.

1 Individuals 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. § 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C. § 552, rather than Privacy Act requests, for individuals who are not United States citizens or aliens lawfully admitted for permanent residence.

2 Signature of individual who is the subject of the record(s) sought.

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