10-945 Certification of Identity and Consent

NPS Form 10-945 (Rev. 10/2016) OMB Control No. 1024-0280

National Park Service Expiration Date ##/##/####

CERTIFICATION OF IDENTITY AND CONSENT

Requester Information (Required)
Full Name of Requester1				Case Number2 (if known)
     				     
Social Security Number	Date of Birth		City of Birth				State of Birth			Country of Birth
     	     		     				     			     
OPTIONAL:
Street Address
     
City					State	Zip Code			Country
     					     	     			     
Telephone Number				Email Address
     				     
Verification of Requester's Identity (Complete this section only if you are making a request for records about yourself.) I declare under the penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and I am the person named in Section 2. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more than $10,000, or by imprisonment for 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.
Signature4								Date
								     
OPTIONAL: Consent to Release Information to a Third Party. By completing this section, you authorize information relating to you to be released to another person, such as a family member or legal counsel. Pursuant to 5 U.S.C. § 552a(b), I authorize the National Park Service to release my records (defined above) to:
Full Name		Full Mailing Address
     		     

¹ Name of individual who is the subject of the record(s) sought.

² Individual 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 National Park Service may be unable to locate any or all records pertaining to you.

⁴ Signature of individual who is the subject of the record sought.

NOTICES

Privacy Act Statement

Authority: Uniform Federal Crime Reporting Act, 28 U.S.C. 534; Intelligence Reform and Terrorism Prevention Act of 2004 (Pub. L. 108–458); Homeland Security Act of 2002 (Pub. L. 107–296); USA PATRIOT ACT of 2001 (Pub. L. 107–56); USA PATRIOT Improvement Act of 2005 (Pub. L. 109–177); Tribal Law and Order Act of 2010 (Pub. L. 111–211); Homeland Security Presidential Directive 7—Critical Infrastructure Identification, Prioritization, and Protection; Homeland Security Presidential Directive 12—Policy for a Common Identification Standard for Federal Employees and Contractors; Criminal Intelligence Systems Operating Policies, 28 CFR part 23. Authority of Public Law 101-509.

Purpose: Verify a requester’s identity and retrieve responsive records in order to respond to requests for copies of incident records from persons involved or injured in incidents, owners of property damaged in such incidents, or these individuals’ duly verified insurance companies, representatives, and/or attorneys.

Routine Uses: In addition to those disclosures generally permitted under 5 U.S.C.552a(b) of the Privacy Act, records or information contained in this system may be disclosed outside NPS as a routine use pursuant to 5 U.S.C. 552a(b)(3) to other Federal, State, territorial, local, tribal, or foreign agencies and other authorized organizations and individuals based on an authorized routine use when the disclosure is compatible with the purpose for which the records were compiled as described under the system of records notice for this system.

Disclosure: Providing your information is voluntary, however, failure to provide all requested information may impede our ability to locate any or all records pertaining to your request. You are asked to provide your social security number only to facilitate the identification of records relating to you. Without your social security number, we may be unable to locate any or all records pertaining to you.

Information Regarding Disclosure of Your Social Security Number Under Public Law 93-579 Section 7(b): Your Social Security Number (SSN) is needed to identify records unique to you. Failure to disclose your SSN may prevent or delay the processing of your request. The authority for soliciting your SSN is 31 U.S.C. 7701. The information gathered through the use of the SSN will be used only as necessary for processing this request and collecting and reporting any delinquent financial obligations. Use of the social security number will be carried out in accordance with established regulations and published notices of system of records.

Paperwork Reduction Act Statement

We are collecting this information subject to the Paperwork Reduction Act (44 U.S.C. 3501) to provide the park managers the information needed to enable the NPS to locate applicable records maintained by the units of the NPS and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974. Required information includes sufficient personally identifiable information and/or source documents as applicable. Failure to provide the required information identified on NPS Form 10-945 may result in the NPS being unable to take any action on the request. 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.

Estimated Burden Statement

Public reporting for this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Information Collection Officer, National Park Service, 1201 Oakridge Drive, Fort Collins, CO 80252. Please do not send your completed form to this address.

RECORDS RETENTION - TEMPORARY. Destroy/delete 3 years after closure. (NPS Records Schedule Management and Accountability) (Item 10D) (N1-79-08-9))