Form DD Form 3216 DD Form 3216 MILITARY ONESOURCE INDIVIDUAL FREEDOM OF INFORMATION ACT

MILITARY ONESOURCE
INDIVIDUAL FREEDOM OF INFORMATION ACT/PRIVACY ACT REQUEST

OMB No. 0704-MTPR
Expires TBD

The public reporting burden for this collection of information is estimated to average ## hours/minutes 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 this burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden, 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 COMPLETED FORM TO THE ABOVE ORGANIZATION.

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 136, Under Secretary of Defense for Personnel and Readiness; 5 U.S.C. 552, Freedom of Information Act, as amended; 5 U.S.C. 552a, Privacy
Act of 1974, as amended; 32 CFR part 286, DoD Freedom of Information Act (FOIA) Program; 32 CFR part 310, Protection of Privacy and Access and Amendment of
Individual Records Under the Privacy Act of 1974; DoD Directive 1322.18, Military Training; DoD Instruction (DoDI) 1342.22, Military Family Readiness; DoDI 6490.06,
Counseling Services for DoD Military, Guard and Reserve, Certain Affiliated Personnel, and Their Family Members; and DoDI 1322.26, Distributed Learning (DL); DoD
Directive, 5400.07, DoD Freedom of Information Act (FOIA) Program; DoD Instruction 5400.11, DoD Privacy and Civil Liberties Programs; DoD Manual 5400.07, DoD
Freedom of Information Act (FOIA) Program; DoD 5400.11–R, DoD Privacy Program; and Executive Order 9397 (SSN), as amended.
PURPOSE: To process, track, and report access requests and administrative appeals for Military OneSource records under the FOIA, and access and amendment requests
and administrative appeals for Military OneSource records under the Privacy Act.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 522a(b) of the Privacy Act of 1974, as amended. Pursuant to 5 U.S.C. 522a(b)(3), records
may be disclosed as a routine use Tto contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative
agreement, or other assignment for the federal government when necessary to accomplish an agency function related to this system of records. A complete list of routine
uses may be found in the applicable System of Records Notice, DoD–0008, Freedom of Information Act and Privacy Act Records (FOIA/PA Records) at: https://
www.federalregister.gov/d/2021-27710
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in your request not being processed.

HOW TO USE THIS FORM
Fields on this form should be used to request information maintained in the Military OneSource electronic Case Management System (DPR 45: Military
OneSource Business Operations Information System) as outlined below.
In order to obtain the most complete record possible, all individuals who are the subject of, or a participant listed within, a record must submit a signed
copy of this form providing consent to the release of information maintained about themselves within the records. Other participants may include a
current or former spouse, current or former partner, child, other family member, etc. who participated in non-medical counseling or another Military
OneSource service with the subject. For couples or family sessions, this means all participants should submit a signed request;, otherwise information
within your record may be redacted to protect the privacy of these other participants. For participants who are minor dependent(s) or ward(s), a request
should be submitted on their behalf by a legal guardian.

NEEDS DD67

For all requests, complete the following sections:
• Section 1
• Section 2
• Section 3

For requests for records involving minor dependent(s) or ward(s), the following section must also be completed:
• Section 4

Part 1 – Request Details
Section 1 – Subject of the Records Request
The individual to whom a record pertains is described as the subject of a record. If you are requesting information from your own Military OneSource
Record or related to your own participation in Military OneSource services, the subject is yourself. If you are requesting information maintained in a
minor dependent or ward’s Military OneSource Record or related to a minor dependent or ward’s participation in Military OneSource services, the
subject is the minor dependent or ward. All individuals who are the subject of, or participant listed within, a record, must submit a copy of this form
signed by themselves, or by their legal guardian, as appropriate. Other participants may include a current or former spouse, current or former partner,
child, other family member, etc. who participated in non-medical counseling or another Military OneSource service with the subject
Other Names Previously Used:

Full Name (First, Middle, Last):

Current Address:

Date of Birth (YYYYMMDD):

Branch of Service:

Phone Number:

Email Address:

Section 2 – Nature of the Request
Military OneSource provides a large array of services. To best facilitate a timely and accurate response, please provide any details about the types of
Military OneSource records sought. For more information on these services, visit: https://www.militaryonesource.mil/about-us/
Description of the records sought:

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Is this request in support of the release of couples or family counseling records?
Yes
No
If yes:
I authorize the release of information related to my participation, or the participation of my minor dependent/ward, in Military OneSource services to
, if contained within this individual’s record.
(Full Name)

Part 2 – Signatures and Consent
This request must be accompanied by either a signed unsworn declaration, or notarized statement, for each of the below sections, as appropriate. To
facilitate DoD’s validation of the request, please provide either a physical (wet ink) signature or digital signature associated with a DoD Common
Access Card. A typed name alone will not be considered a valid signature.
Section 3 – Subject Signature
To authorize the release of the records requested above, please sign below. For release of records related to minor dependent(s) or ward(s), skip to
Section 4.
If executed within the United States, its territories, possessions, or commonwealths:
I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct, and that I am the person named above in Section 1
and requesting the release of my records.
Executed On (YYYYMMDD):

Printed Name:

Signature of Subject:

If executed outside the United States:
I declare (or certify, verify, or state) 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 in Section 1 and requesting the release of my records.
Executed On (YYYYMMDD):

Printed Name:

Signature of Subject:

NEEDS DD67

Section 4 – Parent/Guardian Consent

To authorize the release of records, on or related to minor dependent(s) or ward(s) executed within or outside the United States:

I declare (or certify, verify, or state) under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and
that I have the legal responsibility to care for the minor child/children or ward named in Section 1.
Executed On (YYYYMMDD):

Printed Name:

Signature of Subject:

Office of the Secretary of Defense/Joint Staff Freedom of Information Act Requester Service Center
155 Defense Pentagon, Washington DC 20301-1155, or Fax: 571-372-0500.
http://www.esd.whs.mil/FOID/foi

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