Form 507-1 Certification of Identity

OMB APPROVED

OMB NO. 0412-0589

EXPIRES: 04-30-2021

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):      

Authority for Collection of Information: to 5 U.S.C. § 301; 5 U.S.C. § 552 (Freedom of Information Act (FOIA)); 5 U.S.C. § 552a (Privacy Act); 44 U.S.C. § 3101; 22 C.F.R. § 212; and the applicable executive order(s) governing classified national security information.

Principal Purpose(s) for Which Information Collected is to be Used: This Form collects your Personally Identifiable Information (PII) to be used by USAID to process your request in exercise of your rights to your records under the Privacy Act or to locate and provide you, as a requester under FOIA, records responsive to your FOIA request. Privacy Act rights are exercisable only by requesters who are U.S. citizens or aliens lawfully admitted for permanent residence.

Routine Uses: Information in your records is used for identification. In connection with a Privacy Act request, the information also enables USAID to locate records in its systems of records associated with requestor. This information may also be disclosed in accordance with any current and future blanket routine uses established for the systems of records applicable to this collection. Use and disclosure of your information outside of USAID may also occur in accordance 5 U.S.C. 552a(b) of the Privacy Act and in accordance with the other routine uses set out in USAID-25, the USAID system of records notice (SORN) referenced below.

Whether Disclosure is Mandatory or Voluntary and Effect on Individual of Not Providing Information: Providing the information required by the USAID Form 507-1, Certification, is voluntary. However, failure to provide the requested information may result in USAID not being able to process your request under the Privacy Act or 1974 or FOIA, as appropriate.

SORN: USAID-25, Freedom of Information Act, Privacy Act, and Mandatory Declassification Review Requests Records (79 FR 7164, February 6, 2014).

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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