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Posted on July 5, 2013 at 12:10 AM

My street address:___________________________________

My city, state, and zip:_________________________________

July 4, 2013

Federal Bureau of Investigation

Records/Information Dissemination Section

170 Marcel Drive

Winchester, VA 22602-4843


Dear Sir or Madam:

This is a request for records under theprovisions of the Freedom of Information Act and the Privacy Act. Pleaseprocess this request under both statutes to release the maximum number ofrecords.

I request copies of all files,correspondence, or other records concerning myself. To assist you with thissearch I am providing the following information about myself:

My full name: ________________________

Other names used: ________________________

My date of birth: ________________________

My place of birth: ________________________

My Social Security number: _________________

Please search both your automated indices andthe older general (manual) indices, as well as all Field Offices.

This is an individual request for researchand study purposes, and I agree that I will pay up to $_____ for fees, ifnecessary. Please notify me in advance if fees are expected to exceed thatamount. If the file is likely to result in more than 250 pages, I wouldappreciate receiving a digital copy of the file on a CD-ROM rather than inpaper form.

If you have any questions, please call me at____________________.

Under penalty of perjury, I hereby declarethat I am the person named above and I understand that any falsification ofthis statement is punishable under the provisions of Title 18, United StatesCode (U.S.C.), Section 1001 by a fine of not more than $10,000 or byimprisonment of not more than five years, or both; and that requesting orobtaining any record(s) under false pretenses is punishable under theprovisions of Title 5, U.S.C., Section 552a(i)(3) as a misdemeanor and by afine of not more than $5,000.



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