ED-EMVF-004.2 Privacy Act Request Form

UNITED STATES DEPARTMENT OF EDUCATION
Office of the Executive Secretariat
Freedom of Information Act (FOIA) Service Center

OMB Number: 1880-0546
Expiration Date: XX/XX/XXXX

PRIVACY ACT REQUEST FORM

Use this form to request U.S. Department of Education records/information. Submit completed form and documentation via email
to: [email protected]; fax 202-401-0920; or mail to U.S. Department of Education, Office of the Executive Secretariat,
400 Maryland Avenue, SW, LBJ 7W106, Washington, DC 20202-0121, Attn: Privacy Act Request.
REQUESTER INFORMATION
Title

First Name

Last Name

M.I.

Business Name

Title

Address

Bldg/Apt#

City

State

Phone Number

Fax Number

Zipcode

Email

NOTE: If you are a third party, the subject (or minor subject's parent or guardian) must consent to release of requested
Privacy Act protected records. You are required to submit a Certification of Identity and Consent Form
http://www2.ed.gov/policy/gen/leg/foia/pa_statement.html with your Privacy Act Request Form. You are also required
to submit a Certification of Identity and Consent Form along with this form when requesting student loan records.
Please provide a description of documents that are being requested. Be as specific as possible with regard to names, dates,
places, events, subjects, etc. If known, you should include any file designations or descriptions for the records that you are
requesting.

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UNITED STATES DEPARTMENT OF EDUCATION
Office of the Executive Secretariat
Freedom of Information Act (FOIA) Service Center

OMB Number: 1880-0546
Expiration Date: XX/XX/XXXX

PRIVACY ACT REQUEST FORM

ADDITIONAL COMMENTS

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 subject named above or the parent or guardian of the minor subject named above. I understand that any falsification of
this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine under that title 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. Section 552a(i)(3) by a fine of not more than $5,000.

Signature
Privacy Act Statement.
In accordance with 34 CFR Section 5b.5(b)(2) 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 U.S. Department of
Education systems of records are not wrongfully disclosed by the Department. 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).
Public Burden Statement.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid
OMB control number. The valid OMB control number for this information collection is 1880-0546. Public reporting burden for this collection of information
is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under
34 CFR Section 5b.5(b)(2). If you have comments or concerns regarding the status of your individual submission of this form, please contact the US
Department of Education's FOIA Service Center, 400 Maryland Avenue, SW, LBJ 7W106, Washington, DC 20202-0121 directly. [Note: Please do not return
the completed form to this address.]

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