Public Law 93-579 states in part: "The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy by requiring Federal agencies ... to permit and individual to determine what records pertaining to him are collected, maintained, used, or disseminated by such agencies." The following questions are based upon that act and are necessary in order that this individual may make a reasonable determination concerning divulgence of information to this agency.

Fill out the form completely. If any question does not apply, mark the answer with “N/A” or “Not applicable.” Do not leave any question blank. 

Public Servant Information 

1. Full Legal Name: 

__________________________________________________________ 

2. Residence Address 

__________________________________________________________ 

City __________________________State _______ Zip ____________ 

Department Information

3. Name of department, bureau, or agency by which public servant is employed: 

__________________________________________________________ 

City __________________________State _______ Zip ____________ 

Supervisor's name: 

__________________________________________________________ 

4. Mailing address 

__________________________________________________________ 

City __________________________State _______ Zip ____________ 

Public Servant Duty 

5. Will public servant uphold the Constitution of the United States? 

__________________________________________________________ 

6. Did public servant furnish proof of identity? 

__________________________________________________________ 

7. What was the nature of proof? 

__________________________________________________________ 

8. Will public servant furnish a copy of the law or regulation which authorizes this investigation? 

__________________________________________________________ 

9. Will the public servant read aloud the portion of the law authorizing the questions he will ask? 

__________________________________________________________

Nature of Investigation 

10. Are the answers to the questions voluntary or mandatory? 

__________________________________________________________ 

11. Are the questions to be asked based upon a specific law/regulation, or are they being used as a discovery process? 

__________________________________________________________ 

12. What other uses may be made of this information? 

__________________________________________________________ 

13. What other agencies may have access to this information? 

__________________________________________________________ 

__________________________________________________________ 

14. What will be the effect upon me if I should choose not to answer any part or all of these questions? 

__________________________________________________________ 

__________________________________________________________ 

__________________________________________________________ 

Basis for Investigation 

15. Name of person in government requesting that this investigation be made. 

__________________________________________________________ 

16. Is this investigation 'general' or is it 'special'? 

__________________________________________________________ 

17. Have you consulted, questioned, interviewed, or received information from any third party relative to this investigation? 

__________________________________________________________ 

18. If so, the identity of such third parties: 

__________________________________________________________ 

__________________________________________________________ 

__________________________________________________________ 

Expected Results of Investigation

19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the requested information? 

__________________________________________________________ 

Agency Information 

20. Is there a file of records, information, or correspondence relating to me being maintained by this agency? ______________ 

If yes, which? 

__________________________________________________________ 

__________________________________________________________ 

__________________________________________________________ 

21. Is this agency using any information pertaining to me which was supplied by another agency or government source? 

__________________________________________________________ 

__________________________________________________________

22. May I have a copy of that information? ______________ If not, why not? 

__________________________________________________________ 

__________________________________________________________ 

If so, how may I obtain a copy of that information? 

__________________________________________________________ 

__________________________________________________________ 

23. Will the public servant guarantee that the information in these files will not be used by any department other than the one by whom he is employed? __________ 

If not, why not? 

__________________________________________________________ 

__________________________________________________________ 

Affirmation

 If any request for information relating to me is received from any person or agency, you must advise me in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided by the act.

I swear (affirm) that the answers I have given to the foregoing questions are complete and correct in every particular. 

Printed name: ___________________________________________________ 

Signature: ___________________________________________________ 

Date: ________(month)_________(day)___________________(year) 

First Witness Printed Name: ________________________________________ 

First Witness Signature: ________________________________________ 

Second Witness Printed Name: ______________________________________ 

Second Witness Signature: ________________________________________ 

Authorities for Questions: 

1,2,3,4 In order to be sure you know exactly who you are giving the information to. Residence and 

business addresses are needed in case you need to serve process in a civil or criminal action upon this individual. 

5 All public servants have taken a sworn oath to uphold and defend the constitution. 

6,7 This is standard procedure by government agents and officers. See Internal Revenue Manual, MT- 

9900-26, Section 242.133. 

8,9,10 Title 5 USC 552a, paragraph (e) (3) (A) 

11 Title 5 USC 552a, paragraph (d) (5), (e) (1) 

12,13 Title 5 USC 552a, paragraph (e) (3) (B), (e) (3) (C) 

14 Title 5 USC 552a, paragraph (e) (3) (D) 

15 Public Law 93-579 (b) (1) 

16 Title 5 USC 552a, paragraph (e) (3) (A) 

17,18 Title 5 USC 552a, paragraph (e) (2) 

19 Title 5 USC 552a, paragraph (d) (5) 

20,21 Public Law 93-579 (b) (1) 

22 Title 5 USC 552a, paragraph (d) (1) 

23 Title 5 USC 552a, paragraph (e) (10)