EFTA00022170.pdf

Type: pdf
Source set: data-set-8

Extracted text

U.S Department of Justice
Certification of Identity
FORM APPROVED OMB NO. 11034016
EXPIRES I0/3I/l3
Privacy Act Statement. In accordance with 28 CFR Section 16.41(d) personal data sufficient to identify the individuals submitting requests by
mail under the Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The purpose of this solicitation is to ensure that the records of individuals
who are the subject of U.S. Department of Justice systems of records are not wrongfully disclosed by the Department. Requests will not be
processed if this information is not furnished. False information on this form may subject the requester to criminal penalties under I8 U.S.C.
Section 1001 and/or 5 U.S.C. Section 552a(iX3).
Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Suggestions for reducing this burden may be submitted to the Office of Information and Regulatory Affairs, Office of Management
and Budget, Public Use Reports Project (1103-0016), Washington, DC 20503.
Full Name of Requester Michael C. Miller
Citizenship Status 2 United States
Social Security Number 3
Current Address 1114 Avenue of the Americas, New York, NY 10036
Date of Birth
Place of Birth
I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person
named above, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine of
not more than $10,000 or by imprisonment of not more than five years or both, and that requesting or obtaining any record(s) under false
pretenses is punishable under,the provisions
5 U.S.C. 552a(i)(3) by a fine of not more than $5.000.
Signature 4
Date 8/23/2019
OPTIONAL: Au…

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