Public Law 93-579 states in part: “The purpose of this Act is to provide certain safeguards for an individual against invasion of privacy by requiring federal agencies… to permit an individual to determine what records pertaining to him are collected, maintained, used, or disseminated by such agencies.”
The following questions are based upon that act and are necessary in order that this individual may make a reasonable determination concerning divulgence of information to this agency.
1. Name of public servant: _____________________________________________________________
2. Residence address __________________________________________________________________
____________________________________________________________________________________________
3. Name of department of government, bureau, or agency by which public servant is employed:
____________________________________________________________________________________________
Supervisor’s name __________________________________________________________________
4. Agency mailing address _____________________________________________________________
____________________________________________________________________________________________
5. Will public servant uphold the Constitution for the United States
6. Did public servant furnish proof of identity? _______________________________________________
7. What was the nature of the proof? ____________________________________________________
8. Will public servant furnish a copy of the law or regulation authorizing this investigation? _____________
9. Will the public servant read aloud that portion of the law authorizing the questions s/he will ask? _______
10. Is answering these questions voluntary or mandatory? _______________________________
11. Are your questions based upon a specific law or regulation, or are they being used as a discovery process? ____________________________________________________________________________________________
12. What other uses may be made of this information? _________________________________________
13. What other agencies may have access to this information? __________________________________
14. What will be the effect upon me if I should choose to not answer any part or all of these questions?
____________________________________________________________________________________________
15. Name of person in government requesting that this investigation be made: ____________________
16. Is this investigation “general” or is it “special”? ____________________________________________
17. Have you consulted, questioned, interviewed, or received information from any third party relative to this
investigation? _________________________________________________________________________
18. If so, what is the identity of such third parties? ____________________________________________
19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information which you seek?
______________________________________________________
20. Is there a file of records, information, or correspondence relating to me being maintained by this agency? ______________________________________________________________________________
21. Is this agency using any information pertaining to me that was supplied by another agency or
government source? ___________________________________________________________________
22. Have you inspected any information or document relating to me from this agency or any other? ________
23. May I inspect these files? ________________________________________________________________
24. May I have a copy of these files? __________________________________________________________
25. Will the public servant guarantee that the information in these files will not be used by any department other than the one by whom s/he is employed? ___________________________________________
If not, why not? ______________________________________________________________________
I SWEAR (OR AFFIRM) THAT THE ANSWERS I HAVE GIVEN TO THE ABOVE QUESTIONS ARE COMPLETE AND CORRECT IN EVERY PARTICULAR.
_________________________________________
Signature of Public Servant
____________________________________________________________________________________________
Authorization for Public Servant Questionnaire
If any request for information relating to me is received from any person or agency, you must advise me in writing before releasing such information. Failure to do so may subject you to civil or criminal action as provided by the Act.
The Privacy Act of 1974 (Public Law 93-579) is an amending law to Title 5, United States Code, section 552; and is included in Title 5 as section 552a. This Act gives me full rights to know what information is being collected and maintained about me and for what uses and purposes (see Sec. 2(b)(1)).
QUESTION NUMBER AUTHORIZATION
1, 2, 3, 4 In order to be sure exactly to whom I am furnishing information, residence and addresses are needed in case I need to serve process on this individual in a civil or criminal action.
5 ALL public servants have taken a sworn oath to uphold and defend the Constitution. A copy of this oath may be obtained under the Freedom of Information Act, and by writing the Government Employment or Civil Service Office.
6, 7 This is standard procedure by government agents and officers. I.R. Manual MT-9900-26, section 242.133.
8, 9, 10 Title 5, U.S. Code, section 552a, paragraph (e)(3)(A)
11 Title 5, U.S. Code, sect. 552a, paragraph (d)(5)(e)(1)
12, 13 Title 5, U.S.
14 Title 5, U.S. Code, section 552a, paragraph (e)(3)(D)
15 Public Law 93-579 (b) (1)
16 Title 5, U.S. Code, section 552a, paragraph (e)(3)(A)
17, 18 Title 5, U.S. Code, section 552a, paragraph (e)(2)
19 Title 5, U.S. Code, section 552a, paragraph (d)(5)
20, 21, 22 Public Law 93-579 (b) (1)
23, 24 Title 5, U.S. Code, section 552a, paragraph (d)(1)
25 Title 5, U.S. Code, section 552a, paragraph (e)(10)
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