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U.S Department of Justice Certification of Identity FORM APPROVED OMB NO. 1103-0016 EXPIRES 10/31/13 Privacy Act Statement. In accordance with 28 CFR Section 16.41 (d) personal dita sufficient to identily the individuals subnitting requests by mail under the Privacy Act of 1974, 5 US.C. Section 5324, 15 required. The purpose of this solicitation is to ensure that the records of individuals who are the subject of U.S. Department of Justice systems of records are pol wrongfully disclosed by the Department, Requests will aut be processed if this information is not furnished. False information on this form may subject the requester to crinimal penalties under 18 U.S.C. Section 1001 andfor 5 U.S.C. Section 552atij(3}. Public reporting burden for this collection of information is estimated to average 0.50 hours 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. Suggestions for reducing this burden may be submitted to the Office of Information and Regulatory Affairs, Office of Munagement and Budget. Public Use Reports Project (1103-0016). Washington, DC 20503. Full Name of Requester ' Citizenship Status Social Security Number * Current Address Date of Birth Place of Birth I declare under penally of perjury under the laws of the United States of America that the foregoing is true and correct, and that | am the person named above, and [ understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine of not more than 310,000 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. 5524q)(3) by a fine of not more than $5,000. Signature 4 Date OPTIONAL: Authorization to Release Information to Another Person This form is also to be completed by a requester who Is authorizing information relating to himself or herself to be reicased to another person. Further, pursuant lo 5 U.S.C. Section 552a(b), [authorize the U.S. Deparment of Justice to release any and all information relating bo me to Print or Type Name Name of individual who is the subject of the record(s) sought. 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 3 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom of [oformation Act requests pursuant ta 5 U.S.C, Section 582, rather than Privacy Act requests, for individuals whe are nat United States citizens or ahens lawfully adnutted for permanent residence. * Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the identification of records relating to you. Without your social security number, the Department may be unable to locate any or all records pertaining to you. , Signature of individual who is the subject of the record sought. FORM DO]-361 DOJ-OGR- 00023842