Consent for Disclosure of Records Protected under the Pr

CONTROLLED//PRVCY
(When filled-in)

The Department of the Treasury

OMB Control No. Expiration
Date: MM/DD/YYYY

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 Treasury (“Treasury” or the “Department”) must meet the
requirements of the Privacy Act of 1974, 5 U.S.C. 552a, and Treasury Privacy Act regulations, 31 CFR Part 1, Subpart C.
Completed forms and documentation may be submitted to the Privacy Act System Manager identified in the applicable
system of records notice (SORN) or the Privacy Officer at the Treasury bureau or office where the records are located.
Requests for information and specific guidance on where to send requests for records should be addressed to: Privacy Act
Request, Departmental Offices, Director, FOIA and Transparency, Department of the Treasury,1500 Pennsylvania Avenue NW,
Washington, DC 20220. Requests may also be submitted: on the Treasury/FOIA portal, which can be found at:
https://home.treasury.gov/footer/freedom-of-information-act/submit-a-request; or by email at [email protected].
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. Requests seeking access to Privacy
Act records are subject to verification of identity to protect individual privacy and ensure confidential Privacy Act information
is not improperly released. 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.

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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The Department of the Treasury

Description of Requested Records
Identify the Treasury bureau, office, or program that maintains the requested records, the applicable system of records
notice, 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 you are seeking.

Recipient Information
E-mail or Mailing 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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The Department of the Treasury
Privacy Act Statement: In accordance with 5 U.S.C. 552; Privacy Act of 1974, 5 U.S.C. 552a; 5 U.S.C. 301; 44 U.S.C. 3101; EO 9397, as amended
by EO 13487; and 44 U.S.C. 3534 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 Department of the
Treasury (“Treasury” or the “Department”) systems of records are not wrongfully disclosed by the Department.
The information you furnish may be shared in accordance with the routine uses outlined in the Treasury .004 - Freedom of Information Act/Privacy Act
Request Records - 81 FR 78266 (November 7, 2016) and Treasury .015 General Information Technology Access Account Records – 85 FR 73353
(November 17, 2020).
Requests will not be processed if this information is not furnished. False information on this form may subject the requestor to criminal penalties under
18 U.S.C. 1001 and/or 5 U.S.C. 552a(i)(3).
Records Disposition: Temporary – 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 – 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
Treasury 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. 1505-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 Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C.
20220, or via email at [email protected]. Please do not send your completed forms to this address.

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