Form DD Form 3214 DD Form 3214 CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PR

CUI (when filled in)

CONSENT FOR DISCLOSURE OF RECORDS PROTECTED UNDER THE PRIVACY ACT

OMB No. XXXX-XXXX
Expires YYYYMMDD

The public reporting burden for this collection of information is estimated to average 45 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. 113, Secretary of Defense; 42 U.S.C 2000ee–1, Privacy and Civil Liberties Officers; 32 CFR part 310, Protection of Privacy
and Access and Amendment of Individual Records Under the Privacy Act of 1974; 32 CFR part 286, DoD Freedom of Information Act (FOIA) Program;
5 U.S.C. 552a, Privacy Act of 1974, as amended; DoD Directive, 5400.07, DoD Freedom of Information Act (FOIA) Program; and DoD Instruction
5400.11, DoD Privacy and Civil Liberties Programs.
PURPOSE(S): To obtain consent and verify the identity of individuals requesting access to records protected under the Privacy Act.
ROUTINE USE(S): To third parties and individuals, Members of Congress or their staff when they request the information on behalf of the individual
who is the subject of the record, provided the individual has given written authorization or consent for the request. To 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. The DoD Routine Uses can be found in 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 may result in delay or denial of access to the requested records.
Please read the Instructions on the last page before completing this form.
Information Required for Identity-Proofing and Authentication
This information is required for the agency to verify your identity.
1. Subject of the Record
Legal Name (Last, First, Middle Initial)
Relationship

NEEDS DD67

Self

Parent/
Sponsor

Custodial
Guardian

Legal
Representation

Other

2. Legal Name of Requester (Last, First, Middle Initial)

3. Current Address (Include City, State, and Zip Code. Or APO/FPO if outside of the Continental United States)

4. Date of Birth (mm-dd-yyyy)

7. Preferred Email Address

5. DoD Identification Number (Where applicable) 6. Preferred Phone Number (Please include area
code or DSN, where applicable)

8. Branch of Service (Where applicable)

9. Supplemental Identifiers (Include additional information to locate the record; e.g. other names used, permanent resident ("greencard") number,
passport number, DoDEA student number. Please review the INSTRUCTIONS on the last page for additional information. DO NOT include SSNs
or Classified Information)

10. Description of the Records Sought (Describe what records are being requested and related SORN number. Please review the INSTRUCTIONS on
the last page for additional information. DO NOT include SSNs or Classified Information)

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Controlled by: DoD
CUI Category: PRVCY
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LDC: FEDCON
POC: [email protected]

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11. Recipient Information
Name

Street Address

City

State

Daytime Phone Number

E-Mail

Zip Code

12. Consent and Signature (Please provide an authorized signature. A typed name alone will not be considered a valid signature and the request will
not be processed)
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 and requesting access to my records, or records that I am entitled to request as the parent/sponsor 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 pretense is
punishable under the provisions of 5 U.S.C § 552a(i)(3) by a fine of not more than $5,000.
Executed On (mm-dd-yyyy)

Printed Name

Signature

NEEDS DD67

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INSTRUCTIONS
Describe the requested record(s) in detail to permit identification of the record(s). At a minimum, requests should include the following
information:
1. The individual's full name (including maiden name, where applicable) and any other names used;
2. The approximate time period of the records sought;
3. The circumstances that give the individual reason to believe that the Department of Defense maintains a record under the
individual's name or personal identifier;
4. The system of records under which the record is maintained;
5. Although not required, information such as the DoD ID number, permanent resident ("greencard") number, passport number
and other unique identifiers will assist the Department of Defense in validating and processing the request in a timely manner.
A copy of a court order or appointment must be included with the request if you are a parent or legal guardian requesting records of a
minor or an individual who has been declared by a Court of competent jurisdiction to be incompetent or incapacitated. A copy of the
authorization letter or power of attorney must be included if you are an authorized representative.
All individuals who are the subject of the record, parents or sponsors, legally authorized guardians or representatives must sign and
date this form before submitting it to the appropriate office of jurisdiction.
For a complete listing of DoD System of Records Notices, please visit the Privacy and Civil Liberties Directorate webpage, at: https://
dpcld.defense.gov/Privacy/SORNs/

NEEDS DD67

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