Freedom of Information		
and Privacy Act Request


To:

______________________________

_______________________________
   
_______________________________



I____________________________________________ of______________________________

being identified as such person by the notary having affixed his/her signature
hereunder formally request all 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 being the person 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 in force until:____________________ 


Signature of Notary:_____________________________________________




