My street address: ___________________________________
My city, state, and zip: _________________________________
October 22, 2017
Federal Bureau of Investigation
Records/Information Dissemination Section
170 Marcel Drive
Winchester, VA 22602-4843
FREEDOM OF INFORMATION ACT / PRIVACY ACT REQUEST
Dear Sir or Madam:
This is a request for records under the provisions of the Freedom of Information Act and the Privacy Act. Please process this request under both statutes to release the maximum number of records.
I request copies of all files, correspondence, or other records concerning myself. To assist you with this search I am providing the following information about myself:
My full name: ________________________
Other names used: ________________________
My date of birth: ________________________
My place of birth: ________________________
My Social Security number: _________________
Please search both your automated indices and the older general (manual) indices, as well as all Field Offices.
I authorize you to spend up to two hours searching for responsive records, but no more. This is an individual request for research and study purposes, and I agree that I will pay up to $_____ for fees, if necessary. Please notify me in advance if fees are expected to exceed that amount. If the file is likely to result in more than 250 pages, I would appreciate receiving a digital copy of the file on a CD-ROM rather than in paper form.
If you have any questions, please call me at ____________________.
Under penalty of perjury, I hereby declare that I am the person named above and I understand that any falsification of this statement is punishable under the provisions of Title 18, United States Code (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 Title 5, U.S.C., Section 552a(i)(3) as a misdemeanor and by a fine of not more than $5,000.