AD 3123 Privacy Act Consent Form

OMB Control No.: 0503-XXXX
Expiration Date: xx/xx/xxxx
United States Department of Agriculture

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 of a U.S. citizen or
Lawful Permanent Resident consenting to and authorizing disclosure of the records of an individual who has been declared by a court to be incompetent.
Items marked with an asterisk (*) are mandatory fields. Recommended instructions are located on page 2 of this document and linked to
superscripts 1 through 5 in the form.
Information Required for Identity-Proofing and Authentication
This information is required for the agency to verify your identity.
1. *Full Name of Requester1 (Last, First, MI) ___________________________________________________________________________________________
2. *Current Address (Including City, State, and ZIP Code) ______________________________________________________________________________
3. *Date of Birth (mm/dd/yyyy) _______________

4. *Place of Birth (City/State) _________________

5. *Citizenship Status2 ______________________

6. If you are a parent or legal guardian requesting records of a minor or of an individual who has been declared by a court to be incompetent, please enter
the name of the record subject below:
Name of Record Subject: ___________________________________________________________________________________________________
Relationship to Record Subject:

Custodial
Guardian

Parent

Legal
Representative

Other: _________________________

7. *Additional Information Required to Locate Records
Provide any additional information to locate the record, such as the subject’s date of birth or other personal identifying information.
3

8. Description of Requested Records (Describe what records are being requested)4
Requests for access should describe the requested record(s) in sufficient detail to permit identification of the record(s).

9. Recipient Information
*Name of Recipient (Person or Entity) to Whom Disclosure is Authorized: ______________________________________________________________
*Address for receiving the requested information, including city, state, and ZIP code:

10. Declaration Under Penalty of Perjury
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 consenting to and authorizing disclosure of 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 pretense is punishable under the provisions
of 5 U.S.C § 552a(i)(3) by a fine of not more than $5,000.
Signature: _______________________________________________________________
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Date (mm/dd/yyyy): __________________________________
AD-3123

OMB Control No.: 0503-XXXX
Expiration Date: xx/xx/xxxx
United States Department of Agriculture

CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT
1.

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

2.

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. 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.

This information is required for the agency to be able to match the individual's information provided in this request with the records that pertain to
that individual. Although not required, information such as the subject’s Social Security number, permanent resident ("green card") number,
passport number and other personal identifying information will assist the Department in matching the individual's information provided in this
request with the records that pertain to that individual.

4.

Requests for access should describe the requested record(s) in sufficient detail to permit identification of the record(s). At a minimum, requests
should include the individual's full name (including maiden name, if appropriate) and any other names used. Helpful data includes the approximate
time period of the record and the circumstances that give the individual reason to believe that the Department maintains a record under the
individual's name or personal identifier, and, if known, the system of records in which the record is maintained.

5.

For a complete list of the Department's records collections systems, go to the System of Records Notices (SORN) Page: System of Record Notices
(SORN) webpage located at: https://www.usda.gov/home/privacy-policy/system-records-notices

Privacy Act Statement
In accordance with 22 CFR § 171.22 (c) 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 the U.S. Department
of State's systems of records are not wrongfully disclosed by the Department. The information on this form will only be used to verify identification and
will not be shared with other offices or agencies. More information on the routine uses for the system can be found in the System of Records Notice State35, Information Access Program Records5. 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).
Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply
with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid
OMB Control Number. The approved OMB Control Number for this information collection is 0503-NEW. Without this approval, we could not conduct this
information collection. Public reporting for this information collection is estimated to be approximately 0.40 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information
collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden to the OCIO-ISC Privacy Office at: United States Department of Agriculture, 1400 Independence
Avenue, SW, Room 442-W, Washington, DC 20250–3700, Attn: Chief Privacy Officer.

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AD-3123