Privacy Act Request Form

UNITED STATES DEPARTMENT OF EDUCATION
Office of the Secretary
Freedom of Information Act (FOIA) Service Center

OMB Number: 1880-0546
Expiration Date: 07/31/2024

PRIVACY ACT REQUEST FORM

Use this form to request U.S. Department of Education records/information. Submit completed form and documentation via email
to: [email protected] or mail to U.S. Department of Education, Office of the Secretary, 400 Maryland Avenue, SW, LBJ
7W104, Washington, DC 20202-0121, Attn: Privacy Act Request.
REQUESTER INFORMATION
First Name

M.I.

Last Name

Business Name

Title

Address

Bldg/Apt#

City

State AL

Phone Number

Zipcode

Email

NOTE: If you are a third party, the subject (or minor subject's parent or guardian) must consent to release of requested
Privacy Act protected records. You are required to submit a Certification of Identity and Consent Form
http://www2.ed.gov/policy/gen/leg/foia/pa_statement.html with your Privacy Act Request Form. You are also required
to submit a Certification of Identity and Consent Form along with this form when requesting student loan records.
Please provide a description of documents that are being requested. Be as specific as possible with regard to names, dates,
places, events, subjects, etc. If known, you should include any file designations or descriptions for the records that you are
requesting.

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DAA-GRS-2016-0002-0001; SORN 18-04-01

UNITED STATES DEPARTMENT OF EDUCATION
Office of the Secretary
Freedom of Information Act (FOIA) Service Center

OMB Number: 1894-XXXX
Expiration Date: XX/XX/XXXX

PRIVACY ACT REQUEST FORM

ADDITIONAL COMMENTS

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 subject named above or the parent or guardian of the minor subject named above. I understand that any falsification of this
statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine under that title 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. Section 552a(i)(3) by a fine of not more than $5,000.

Signature

Privacy Act Statement
Authorities: The information requested on this form, and the associated evidence, is collected under the Privacy Act of 1974 (Privacy Act), 5 U.S.C. Section
552a, as amended.
Purpose: The primary purpose for providing the requested information on this form is to request access to information under the Privacy Act, or amendment or
correction of records under the Privacy Act. The Department uses the information you provide to (1) verify your identity, and (2) to grant or deny the
information request you are seeking or requesting to amend.
Consequences of Failure to Provide Information: The information you provide is voluntary. However, failure to provide the requested information, and any
requested evidence, may delay access to information or result in denial of your information or amendment request.
Routine Uses: The Department may share the information you provide on this form and any additional requested evidence in accordance with approved routine
uses described in the "Freedom of Information Act and Privacy Act Tracking System" system of records notice, located on the Department's system of records
notice website.

Public Burden Statement.
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. The valid OMB control number for this information collection is 1880-0546. Public reporting burden for this collection of information
is estimated to average 30 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain a benefit under
34 CFR Section 5b.5(b)(2). If you have comments or concerns regarding the status of your individual submission of this form, please contact the US
Department of Education's FOIA Service Center, 400 Maryland Avenue, SW, LBJ 7W104, Washington, DC 20202-0121 directly.

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DAA-GRS-2016-0002-0001; SORN 18-04-01