Di-4017 Consent For Disclosure Of Records Protected Under The Pr

CONTROLLED//PRVCY
(When filled-in)

DI-4017 (01/2022)
U.S. Department of the Interior

OMB Control No. 1093-XXXX
Expiration Date: XX/XX/XXXX

CONSENT FOR DISCLOSURE OF RECORDS
PROTECTED UNDER THE PRIVACY ACT
If you are providing consent and authorizing the agency to disclose your records to another person or entity, please provide
the information below. This form may also be used if you are the parent consenting to and authorizing disclosure of the
records of a minor or the legal guardian consenting to and authorizing disclosure of the records of an incompetent.
Privacy Act requests submitted to the U.S. Department of the Interior (DOI) must meet the requirements of the Privacy Act of
1974, 5 U.S.C. 552a and DOI Privacy Act regulations, 43 CFR Part 2, Subpart K. Completed forms and documentation may
be submitted to the Privacy Act System Manager identified in the applicable system of records notice (SORN) or the
Associate Privacy Officer at the DOI bureau of office where the records are located. DOI bureau and office mailing and
email contact information are available at https://www.doi.gov/privacy/contacts. Privacy Act requests may also be submitted
via email to [email protected]; or by mail to the DOI Privacy Office, 1849 C St NW, Room 7112, Washington, DC
20240, Attention: Privacy Act Request.
The completed form must be signed electronically by using Adobe Acrobat Reader Fill and Sign, or by typing your name in
the signature fields, or may be printed and signed by the requestor prior to submission. A request seeking access to records
regarding you or your minor child is subject to verification of identity to protect individual privacy and ensure Privacy Act
protected information is not released improperly. Please note that we may contact you if we need further information to
verify your identity or to process your request. You should keep a copy of your request as a reference for further
correspondence with DOI.

Information Used for Identity-Proofing and Authentication
This information is required for the agency to verify your identity.

Full Name
Email Address
Current Address

Information for Request by Parent or Legal Guardian (if applicable)
Name of Record Subject
Relationship to Record Subject

Additional Information Required to Locate the Record(s)

This information is required for the agency to be able to match an individual's information provided
in this request with the records that pertain to that individual.

Provide information to identify the
record subject such as Alias, Other
Names Used or Date of Birth

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DI-4017 (01/2022)
U.S. Department of the Interior

Description of Requested Records
Provide the DOI bureau, office, or program that maintains the requested records, the applicable system of records notice
(e.g., DOI-16, Learning Management System), and a clear description of the record(s) including date range, subject
matter, place records were created, and other pertinent details. The description should be specific enough to help us
locate the records.

Recipient Information
Name of Recipient (Person or Entity) to
Whom Disclosure is Authorized
Address for Receiving Records

Signature
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 requesting access to my records, or records that I am entitled to request as the
parent of a minor or the legal guardian of an incompetent, and I understand that any falsification of this statement is
punishable under the provisions of 18 U.S.C. § 1001 by a fine, 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.
Signature
Date

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DI-4017 ( 01/2022)
U.S. Department of the Interior
Privacy Act Statement: In accordance with 43 CFR Part 2, Subpart K, personal information sufficient to identify the individuals requesting access to
records under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of this solicitation is to ensure that the records of individuals who are
the subject of DOI systems of records are not wrongfully disclosed by DOI. Information will be used by DOI officials to process Privacy Act requests and
may be disclosed externally to: the National Archives and Records Administration, Office of Government Information Services for compliance with
Freedom of Information Act requirements, a debt collection agency for collecting debts owed for processing the Privacy Act requests, another Federal
agency to assist in responding to a request, or other organizations as authorized under the Privacy Act or outlined in the routine uses in DOI-57, Privacy
Act Files, 81 FR 45527 (July 14, 2016), 86 FR 50156 (September 7, 2021), which may be viewed at https://www.doi.gov/privacy/sorn. Providing
information is voluntary. 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. § 1001 and/or 5 U.S.C. § 552a(i)(3).
Records Disposition: Temporary, DAA-0048-2013-0001-0001 (DRS 1.1.0001) – Short Term Administration Records. Cutoff after date of reply. Destroy
3 year after cutoff. When a request is denied, or appealed, for Privacy Act amendments, or any erroneous releases: Temporary,
DAA-0048-2013-0001-0002 (DRS 1.1.0002) – Long Term Administration Records. Cutoff after upon agency agreement to amend, final determination by
agency, on expiration of time in which a requestor can file suit, or on final adjudication by the courts, whichever is later. Destroy 7 years after cutoff.
Paperwork Reduction Act Statement: In accordance with the Paperwork Reduction Act (44 U.S.C. 3501, et seq.), the U.S. Department of the Interior
collects information necessary for complying with the mandatory OMB M-21-04 templates for individuals to submit requests for accessing and consenting
to the disclosure of records protected under the Privacy Act of 1974, as amended, 5 U.S.C. 552a. Information requested in this form is required to obtain
or retain a benefit. According to the Paperwork Reduction Act of 1995, 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 control number. OMB has approved this collection of information and assigned
Control No. 1093-XXXX.
Estimated Burden Statement: We estimate public reporting for this collection of information to average 15 minutes, including time for reviewing
instructions, gathering and maintaining data and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect
of the form to the Department Information Clearance Officer, U.S. Department of the Interior, 1849 C Street, Washington, DC 20240, or via email at [email protected]. Please do not send your completed forms to this address.

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