Form BC-300 Certification of Identity

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U.S. Department of Commerce
Form BC-300 Certification of Identity

OMB# 0607-1018
Expiration 06/30/2022

Purpose: The primary purpose for providing the requested information on this form is for parties
to authorize the disclosure of their information, including information retained in case files or a
Record of Proceeding (documents, and if applicable, audio recordings), to an attorney, accredited
representative, qualified organization, or other third party.
Disclosure: To help to ensure that privacy-protected information is not improperly released, a
document such as this form, which verifies your identity, must accompany all requests for access
to records containing your information. You may choose what information you wish to be
disclosed, but failure to fully complete the form, including any additional information requested to
process the request, may delay access to information or result in denial of an information request.
Authorities: The information requested on this form, and the associated evidence, is collected
under the Freedom of Information Act (FOIA), 5 U.S.C. § 552, and the Privacy Act of 1974, 5
U.S.C. § 552a, together with the Department of Commerce regulations at 15 C.F.R. § 4.24(d).
Freedom of Information Act Statement: Requests for information about a person other
than the requester require proper authorization allowing release of the information. If you are
seeking non-public information regarding a person that is not you or a person you represent, the
U.S. Census Bureau recommends having the person who is the subject of the request complete
and sign this form for this purpose. Failure to provide a signed Form BC-300 Certification of
Identity may impede U.S. Census Bureau’s release of information if the disclosure would
constitute a clearly unwarranted invasion of personal privacy. Additionally, please note that prior to
releasing any information, the U.S. Census Bureau assesses the applicability of all FOIA
exemptions. For additional information on submitting a FOIA or Privacy Act Request to the Census
Bureau, see https://www.census.gov/about/policies/foia.Submit_a_Privacy_Request.html.
Paperwork Reduction Act: We estimate that completing the Certification of Identity (Form
BC-300) will take 6 minutes on average. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden, to
[email protected]. This collection has been approved by the Office of Management and
Budget (OMB). The eight-digit OMB approval number that appears at the upper right of the form
confirms this approval. If this number were not displayed, we could not conduct this collection of
information.
Privacy Act Statement: In accordance with 15 CFR Section 4.24(d), the U.S. Census Bureau
requires you provide us with sufficient information to identify you when you submit requests by
mail or otherwise not in person under the Privacy Act of 1974, 5 U.S.C. Section 552a. We take
this step to ensure that we do not wrongfully disclose the records of individuals who are the
subject of U.S. Census Bureau systems of records.
In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, all
or a portion of the records or information contained in this system may be disclosed to authorized
entities, as is determined to be relevant and necessary, outside the Department as a routine use
pursuant to 5 U.S.C. 552a(b)(3) and the published routine uses as identified in the Privacy Act
System of Records Notice DEPT-5, Freedom of Information Act and Privacy Act Request Records.
Providing this information is voluntary, however, if you do not provide it, we will be unable to take
action on your request. If you provide false information on this statement, you may be subject to
criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).

BC-300 (5-17-2022)

FORM BC-300 (5-17-2022)

OMB# 0607-1018: Expiration 06/30/2022

U.S. DEPARTMENT OF COMMERCE
U.S. CENSUS BUREAU

CERTIFICATION OF IDENTITY
PRIVACY ACT STATEMENT
In accordance with 15 CFR Section 4.24(d), the U.S. Census Bureau requires you provide us with sufficient information to identify you when you submit
requests by mail or otherwise not in person under the Privacy Act of 1974, 5 U.S.C. Section 552a. We take this step to ensure that we do not wrongfully
disclose the records of individuals who are the subject of U.S. Census Bureau systems of records. In addition to those disclosures generally permitted under 5
U.S.C. 552a(b) of the Privacy Act, all or a portion of the records or information contained in this system may be disclosed to authorized entities, as is
determined to be relevant and necessary, outside the Department as a routine use pursuant to 5 U.S.C. 552a (b)(3) and the published routine uses as
identified in the Privacy Act System of Records Notice DEPT-5, Freedom of Information Act and Privacy Act Request Records. Providing this information is
voluntary, however, if you do not provide it, we will be unable to take action on your request. If you provide false information on this statement, you may be
subject to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).

Part A. Information Regarding the Subject of the Records Sought
Current Legal Name (Last, First, Middle)

Date of Birth (mm/dd/yyyy) Place of Birth

Other Names You Have Been Known by Since Birth

Current Address in the United States
Street No. and Name

City

Apartment No. or Unit No. (if any)

State

ZIP Code

Telephone Number

Release the following records – (specify the exact records you wish to be released)

Part B. Recipient’s Information
Recipient Status

Self

Parent of minor child whose record(s) is sought

Guardian of individual whose record(s) is sought – Enclose copy of appointing document.
If you are authorizing information related to yourself to be released to another person –
Name of Authorized Recipient (Last, First, Middle)
Recipient’s Organization (if applicable)

Recipient’s Telephone Number

Further pursuant to 5 U.S.C. Section 552a (b), I authorize the U.S. Census Bureau to release the above-described
information relating to me.
Original Signature of Requester

Date

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 I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001
by a fine of not more than $10,000 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. 552a(i)(3) by a fine of not more than $5,000

Original Signature of Requester

Date

Email – Please include to receive a response.