Sample Privacy Act Request Letter

[Date]

[Return Address]

Mr. Carl Martin Ruiz
Director
USDA Office of Civil Rights
1400 Independence Avenue, SW
Washington, DC 20250-9410

Dear Mr. Ruiz:

Under the Freedom of Information Act and the Privacy Act, I am requesting access to [identify the records as clearly and specifically as possible. Include the time period applicable to the records you seek, i.e., 1 month, 2 years, etc.].

Optional: To help identify information about me in your record systems, I am providing the following information: [Full name, current address, date and place of birth, citizenship status, and explanation of contact with the Agency or any other information that would help us distinguish between you and other individuals with the same or similar names. NOTE: While providing this information is optional, providing it may expedite the processing of your PA Request.]

If you deny any part of this request, please cite each specific exemption that you rely on to justify your refusal to release the information and notify me of appeal procedures available under the law.

Please supply the records without informing me of the cost if the fees do not exceed [$_____], which I agree to pay. [Or, if there are any fees charged for duplication of records, please let me know before you fill my request.]

If you have any questions concerning this request, you may contact me at [telephone number].

Sincerely,

[your signature]

I declare under penalty of perjury that I am [list your full name] and the statements contained in this document are true and correct. Executed on: [date]