Form BC-300 Certification of Identity

U.S. Department of Commerce
Form BC-300 Certification of Identity

OMB# 0607-XXXX
Expiration XX/XX/XXXX

Purpose: The primary purpose for providing the requested information on this form is for parties to authorize the
disclosure of their information, including information retained in case files or a Record of Proceeding (documents,
and if applicable, audio recordings), to an attorney, accredited representative, qualified organization, or other third
party.
Disclosure: To help to ensure that privacy-protected information is not improperly released, a document such as
this form, which verifies your identity, must accompany all requests for access to records containing your
information. You may choose what information you wish to be disclosed, but failure to fully complete the form,
including any additional information requested to process the request, may delay access to information or result in
denial of an information request.
Authorities: The information requested on this form, and the associated evidence, is collected under the Freedom
of Information Act (FOIA), 5 U.S.C. § 552, and the Privacy Act of 1974, 5 U.S.C. § 552a, together with the
Department of Commerce 15 C.F.R. § 4.24(d).
Freedom of Information Act Statement: Requests for information about a person other than the requester
require proper authorization allowing release of the information. If you are seeking non-public information regarding a
person that is not you or a person you represent, the U.S. Census Bureau recommends having the person who is
the subject of the request complete and sign this form for this purpose. Failure to provide a signed Form BC-300
Certification of Identity may impede U.S. Census Bureau’s release of information if the disclosure would constitute a
clearly unwarranted invasion of personal privacy. Additionally, please note that prior to releasing any information, the
U.S. Census Bureau assesses the applicability of all FOIA exemptions. For additional information on submitting a
FOIA or Privacy Act Request to the Census Bureau, see
https://www.census.gov/about/policies/foia/privacy_act_requests.html#make-request.
Paperwork Reduction Act: We estimate that completing the Certification of Identity (Form BC- 300) will take 6
minutes on average. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to [email protected]. This collection has been approved
by the Office of Management and Budget (OMB). The eight-digit OMB approval number that appears at the upper
right of the form confirms this approval. If this number were not displayed, we could not conduct this collection of
information.
Privacy Act Statement: In accordance with 15 CFR Section 4.24(d), the U.S. Census Bureau requires you
provide us with sufficient information to identify you when you submit requests by mail or otherwise not in person
under the Privacy Act of 1974, 5 U.S.C. Section 552a. We take this step to ensure that we do not wrongfully
disclose the records of individuals who are the subject of U.S. Census Bureau systems of records.
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all or a portion of the
records or information contained in this system may be disclosed to authorized entities, as is determined to be
relevant and necessary, outside the Department as a routine use pursuant to 5 U.S.C. 552a(b)(3) and the published
routine uses as identified in the Privacy Act System of Records Notice DEPT-5, Freedom of Information Act and
Privacy Act Request Records.
Providing this information is voluntary, however, if you do not provide it, we will be unable to take action on your
request. If you provide false information on this statement, you may be subject to criminal penalties under 18 U.S.C.
Section 1001 and/or 5 U.S.C. Section 552a(i)(3).

FORM BC-300 (11-12-2021)

OMB# 0607-XXXX: Expiration XX/XX/XXXX

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

CERTIFICATION OF IDENTITY
PRIVACY ACT STATEMENT
In accordance with 15 CFR Section 4.24(d), the U.S. Census Bureau requires you provide us with sufficient information to identify you when you submit
requests by mail or otherwise not in person under the Privacy Act of 1974, 5 U.S.C. Section 552a. We take this step to ensure that we do not wrongfully
disclose the records of individuals who are the subject of U.S. Census Bureau systems of records. In addition to those disclosures generally permitted under 5
U.S.C. 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed to authorized entities, as is
determined to be relevant and necessary, outside the Department as a routine use pursuant to 5 U.S.C. 552a (b)(3) and the published routine uses as
identified in the Privacy Act System of Records Notice DEPT-5, Freedom of Information Act and Privacy Act Request Records. Providing this information is
voluntary, however, if you do not provide it, we will be unable to take action on your request. If you provide false information on this statement, you may be
subject to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i) (3).

Part A. Information Regarding the Subject of the Records Sought
Current Legal Name (Last, First, Middle)

Date of Birth (mm/dd/yyyy) Place of Birth – Please print or type
Other Names You Have Been Known by Since Birth

Current Address in the United States
Street Number and Name – Please print or type
City – Please print or type

Apartment Number or Unit Number (if any)
State

Previous Address in the United States (if applicable)
Street Number and Name – Please print or type
City – Please print or type

ZIP Code

Telephone Number

Apartment Number or Unit Number (if any)
State

ZIP Code

Telephone Number

Release the following records – (specify exact records you wish to be released)

Part B. Recipient’s Information
Select this box if recipient information is same as above
Recipient’s Name (Last, First, Middle)

Recipient’s Organization (if applicable)

Recipient’s Mailing Address In Care of Name (if any)

Street Number and Name – Please print or type
City – Please print or type

Apartment Number or Unit Number (if any)
State

ZIP Code

Telephone Number

Recipient’s Email Address

Recipient Status
Self

Guardian of individual whose record(s) is sought – Enclose copy of appointing document.

Parent of minor child whose record(s) is sought

Part C. Authorization to Release Information to Another Person
If you are authorizing information relating to yourself to be released to another person.
Name of authorized recipient

Further pursuant to 5 U.S.C. Section 552a (b), I authorize the U.S. Census Bureau to release the above-described
information relating to me.

Original Signature of Requester

Date

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.
Original Signature of Requester

FORM BC-300 (11-12-2021)

Date