DoD CAF Form 3 Request for Records

REQUEST FOR RECORDS
DOD CONSOLIDATED ADJUDICATIONS FACILITY (DoD CAF)

OMB CONTROL NUMBER: XXXX-XXXX
EXPIRATION DATE: XX/XX/XXXX

INSTRUCTIONS: The use of this form is voluntary and is protected by the Privacy Act of 1974. To request a copy of DoD
CAF records, please complete the appropriate fields below or send a written request to our agency containing the requested
information. The information you provide will be used to identify/retrieve records pertaining to your request. Providing all or
part of this information is voluntary; however, without it, the DoD CAF may not be able to respond to your request. Your
completed form or written request may be submitted via first class mail or by secure e-mail as a scanned attachment.

See Page 2 for DoD CAF contact information and Privacy Act Statements.
1. TYPE OF REQUEST - SELECT ALL THAT APPLY. (THIS SECTION MUST BE COMPLETED)

PRIVACY ACT REQUEST - I request my own records under the Privacy Act of 1974. (Requester must complete
sections 2, 3, 4 and 5.)
I authorize release to another individual. (Requester must complete section 2, 3, 4, 5 and 6)
2. REQUESTER CONTACT INFORMATION (THIS SECTION MUST BE COMPLETED)

Full Name:
Street Address:
City:

Telephone No (Optional):

State:

E-mail (Optional):

Zip Code:

Country:

3. RECORDS REQUESTED - Briefly describe the records you are seeking in enough detail so that we may identify the documents.

Letter of Intent/Statement of Reasons (LOI/SOR)
Documents the DoD CAF relied upon in its preliminary personnel security eligibility decision.
Other:

4. REQUESTER'S IDENTIFYING INFORMATION

Social Security Number:

Date of Birth:

Other Names Used:

U.S. Citizenship:

Yes

No

Place of Birth:
5. VERIFICATION OF REQUESTER'S IDENTITY

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.

Signature:
(Handwritten Signature Required)
DoD CAF Form 3, July 2015

Date:

6. AUTHORIZATION TO RELEASE INFORMATION TO THIRD PARTY (OPTIONAL)

By completing this section, you authorize information relating to you to be released to another person, such as family member or
legal counsel. Pursuant to U.S.C. § 552a(b), I authorize the Department of Defense Consolidated Adjudications Facility to
release my records to:
Address of Third Party:

Name of Third Party:

Signature:
(Handwritten Signature Required)

Date:
DOD CAF CONTACT INFORMATION

Mailing Address:
DoD Consolidated Adjudications Facility
Attn: Privacy Act Office
Building 600, 10th Street
Fort George G. Meade, MD 20755-5615
To e-mail requests: You may scan your request, as an e-mail attachment, and send to:
[email protected]
Please ensure that the security of your e-mail system is adequate for transmitting personally identifiable information.
NOTE: Most adjudicative actions conducted by the DoD CAF are based upon the review of the Office of Personnel Management (OPM)
personnel security background investigations. To obtain a copy of your OPM background investigation, you should contact OPM directly
at OPM-Federal Investigative Services, Attn: Privacy Section, P.O. Box 618, 1137 Branchton Road, Boyers, PA 16018-0618, or visit their
website at www.opm.gov.
Privacy Act Statement:
Authorities: 5 U.S.C. 552a, the Privacy Act of 1974, as amended; 10 U.S.C. 113, Secretary of Defense; 32 CFR part 310 DoD Privacy
Program; 32 CFR part 311, OSD Privacy Program; DoD 5400.11-R, Department of Defense Privacy Program; and E.O. 9397 (SSN), as
amended. Principal Purpose(s): To ensure needed information is collected so that your request for access to the records about you
maintained by the DoD Consolidated Adjudications Facility can be processed. These records will also be used in any Privacy Act appeals
or related litigation. These records are covered by DWHS E04, Privacy Act Case Files found at http://dpcld.defense.gov/Privacy/
SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570753/dwhs-e04.aspx. Routine Use(s): The Law Enforcement,
Congressional Inquiries, Department of Justice for Litigation, National Archives and Records Administration, and Data Breach
Remediation, and Routine Uses found at http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx may apply.
Disclosure: Voluntary. However, if the information needed to locate your records and send your response is not provided, we will not be
able to respond to your request. The Social Security Number is used to retrieve adjudication files.
Public Burden Statement:
The public reporting burden for this collection of information, 0704-0561, is estimated to average 10 mins 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 the burden estimate or burden reduction suggestions to the Department of Defense,
Washington Headquarters Services, at [email protected]. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it
does not display a currently valid OMB control number.

PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS. Responses should be sent to the DoD Consolidated
Adjudications Facility, Attn: Privacy Act Office, Building 600, 10th Street, Fort George G. Meade, 20755.
DoD CAF Form 3, July 2015 (Back)