Privacy Act Records Request Form

Full Name

First NameLast Name

Organization or Department

Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Description of Records Requested

Subject/Person the Records Relate To

First NameMiddle NameLast Name

Relevant Date Range Start

Date

Relevant Date Range End

Date

Type of Records Sought

Preferred delivery method

Preferred format

Best time to contact you

Additional notes or instructions