Form 10003 Form 10003 Consent to Make Inquiries and Release of Information and

OMB Control No. 3095-0068
Expiration date: XX/XX/20XX

Consent to Make Inquiries and Release of Information and Records

Name:
Current Address:

Email address:
Telephone Number:

Agency to which request was made:
Original FOIA/Privacy Act request and appeal number:
In accordance with the Privacy Act of 1974 as amended, I hereby authorize the Office of Government
Information Services to make inquiries on my behalf, including the right to review all documentation that OGIS
deems necessary regarding the Freedom of Information Act and/or Privacy Act request/administrative appeal
that is the subject of my request for OGIS assistance. I understand that any documents I provide to OGIS,
except those provided in confidence, may be copied and forwarded to agency officials as a part of the
mediation/resolution process. I also authorize any Federal department, agency or component to release to OGIS
information and records related to my Freedom of Information Act and/or Privacy Act request/administrative
appeal.

Name (print)

Signature

Date

SEND COMPLETED FORMS TO:
National Archives and Records Administration
Office of Government Information Services
8601 Adelphi Road - OGIS
College Park, MD 20740
Privacy Act and Paperwork Reduction Act Public Burden Statements are on the reverse of this page

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

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NA FORM 10003 (08-19)

OMB Control No. 3095-0068
Expiration date: XX/XX/20XX

Privacy Act Statement
In compliance with the Privacy Act of 1974, as amended, we provide the following information: 44 U.S.C. § 2104 and 5 U.S.C. § 552
authorize us to collect this information. The Office of Government Information Services (OGIS) will use the information provided to
make inquiries on your behalf to facilitate your request for mediation services (to resolve disputes between yourself and Federal
agencies to which you have made request(s) under the Freedom of Information Act and the Privacy Act of 1974, as amended). We
may provide this information to an expert, consultant, volunteer, or OGIS contractor or to other Federal agency personnel on a needto-know basis in order to assist OGIS in performing its statutory duties. You are not required to provide this information. However, if
you do not provide this information, OGIS will not be able to assist you due to legal restrictions.
Paperwork Reduction Act Public Burden Statement
This form is subject to the Paperwork Reduction Act (PRA). You are not required to provide the information requested on a form
that is subject to the PRA unless the form displays a valid OMB control number. The Office of Government Information Services is
collecting and using the information requested on this form to ensure compliance with the Privacy Act of 1974, as amended. We
estimate the information collection public burden to be ten minutes per response, including time for reviewing instructions and
completing and reviewing the form. Send comments regarding the burden estimate or any other aspect of the information collection,
including suggestions for reducing this burden, to National Archives and Records Administration (MP); 8601 Adelphi Road; College
Park, MD 20740-6001. DO NOT SEND COMPLETED FORMS TO THIS ADDRESS.

NATIONAL ARCHIVES AND RECORDS ADMINISTRATION

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NA FORM 10003 (08-19)