Fillable Freedom Of Information/privacy Act Request printable pdf download

Freedom of Information/Privacy Act Request

This Freedom of Information/Privacy Act Request seeks all records of the Federal Bureau

of Investigation, the Terrorist Screening Center, and of the Bureau of Alcohol, Tobacco,

Firearms, and Explosives, regarding the person whose information and certification of

identity is filled in, below. The term “records” is used to reference all information,

including, but not limited to, (1.) documentation that the individual is or ever has been

included in one or more databases referred to as the “Terrorist Identities Database,”

“Terrorist Screening Database,” “No Fly List,” “NICS Index,” and/or the “NICS Audit

Log;” and, (2.) documentation relating to the individual’s submission of an “ATF

Form 4473,” including the manufacturer, model, and serial number from said form.

Please note:

expedited processing is requested. The information sought involves possible questions

about the government’s integrity which will effect public confidence in the government.

fee waiver is requested. Disclosure of the requested information is in the public interest

because it is likely to contribute significantly to public understanding of the operations and

activities of the government. This request is part of a national “Stop the Secrecy!” campaign.

Your Full Name: __________________________________________________________

Citizenship Status:

_______________

Social Security No.:

________________

Current Address: __________________________________________________________

Date of Birth: ___________________

Place of Birth: _____________________

Certification of Identity

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. §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.

Signature: __________________________________

Date: _______________________

Individual submitting a request under the Privacy Act of 1974 must be either “a citizen of the United States or an alien

lawfully admitted for permanent residence,” pursuant to 5 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom

of Information Act requests pursuant to 5 U.S.C. Section 552, rather than Privacy Act requests, for individuals who are not

United States citizens or aliens lawfully admitted for permanent residence.

Providing a Social Security Number is voluntary. It may assist in the identification of records relating to you.

Freedom Of Information/privacy Act Request