Freedom of Information and Privacy Act Request To:______________________________ _______________________________ _______________________________ This letter constitutes my formal request for information pursuant to the provisions of the Freedom of Information and Privacy Acts, 5 USC 552. I am requesting copies of all information maintained by your agency that pertain to myself as described below: Full Name: Current Address: Social Security No.: Date and Place of Birth: Former Addresses (use reverse if more space needed): Date:____________ Signature:__________________________ I, __________________________ a Notary Public in and for the county (city) and state of __________________________ hereby certify that on the ____ day of _______, 19__, before me personally appeared __________________________, who is known by me to be the identical person whose name is subscribed to, and who signed and executed the foregoing instrument. In witness thereof, I have hereunto set my hand and official seal this day and year above. My commission expires:____________ Signature of Notary:__________________ INSTRUCTIONS To find out if you have an FBI (or any federal agency) file and obtain a copy of it, fill out the above information, have this form notarized (you must sign it in front of a notary and provide the notary sufficient identification), and mail to the FBI (or other agency). A request should be sent to each field office that might have files as well as FBI Headquarters. Make a copy of your signed and notarized form for your records. Please note that it is a criminal offense to represent yourself as another in attempt of obtaining information. THIS FORM IS A PUBLIC SERVICE OF GLEN L. ROBERTS You are encouraged to copy this form and distribute to others. Glen L. Roberts is editor of Full Disclosure. Glen L. Roberts, PO Box 1533, Oil City, PA 16301. Email: glr@ripco.com. Web: http://pages.ripco.com:8080/~glr/glr.html FBI Headquarters J Edgar Hoover Bldg 10th & Pennsylvania Ave Washington DC 20535 FBI Box 2058 Milwaukee WI 53201 FBI 219 S Dearborn St #905 Chicago IL 60604 FBI P O Box 3646 Springfield IL 62708 FBI P O Box 1229 Denver CO 80201