Form FDA 3975 FDA 3975 Certification of Identify

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

Form Approved: OMB No. 0910-0832
Expiration Date: 06/30/2020
(See Burden Statement below.)

Certification of Identity

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 Requestor1
Citizenship Status2

Social Security Number3

Current Address

Date of Birth
Place 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 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.
Date

Signature4

1 Name

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

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. Food & Drug Administration to release
any and all information relating to me to the person named below:
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
[email protected]
FORM FDA 3975 (6/17)

“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.”

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