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U.S Department of Justice Certification of Identity FORM APPROVED OMB NO. 1103-0016 EXPIRES 10/31/13 Privacy Act Stalement. In accordance with 28 CPR Section 16.41(d) personal data sufficient to identify dhe individuals subnutling requests by mail under the Privacy Act of 1974, 5 U.S.C. Section 5524, 15 required. The purpose of ihis solicitation is to ensure thal the records of individuals who are the subject af U.S. Department of Justice systems of records are aol wrongfully disclosed by the Department, Requests will not be processed if this information is nut furnished. False information on tus form may subject the requester io crunimal penalties under 18 U.S.C. Section LOO] and/or 5 U.S.C. Section 552afi)(3}. PubHe reporting burden for this colleetion of information is estimate 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 Management 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 ! declare under penalty 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 LOO] 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. 55240)(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 relcased to another person. Further, pursuant to S U.S.C. Section 552a(b), | authorive the U.S. Department of Justice to release any and all infermahon relating to me tox 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 5 ULS.C. Section S52a(a)(2). Requests will be processed as Freedom of [nformation Act requests pursuant ta 5 U.S.C. Section 382, rather thas Privacy Act requests, for individuals who are not United States citizens or ahens lawfully admitted 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 DOJ]-361 DOJ-OGR-00023953