Form ED-EVM.001.1 Perjury Form

UNITED STATES DEPARTMENT OF EDUCATION

FORM APPROVED
OMB NO: 1880-0545
Exp. XX/XX/XXXX

OFFICE OF MANAGEMENT
Office of the Chief Privacy Officer
Certification of Identity and Consent

To ensure Privacy Act protected information is not released improperly, a request that is not made in person seeking access to records regarding you
or your minor child must be accompanied by verification(s) of identity. This form may be signed electronically by using Adobe Acrobat Reader Fill
and Sign, or by typing your name in the signature fields, or may be printed and signed to submit to the Freedom of Information Act (FOIA) Service
Center.
SECTION 1: REQUESTER INFORMATION
Subject's Full Name*1

Tracking Number*2

Citizenship Status*3 (select one)
US Citizen

Alien lawfully admitted for
permanent residence

Social Security Number*4

Date 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 subject named
above or the parent or guardian of the minor subject named above. I understand that any falsification of this statement is punishable under the provisions
of 18 U.S.C. Section 1001 by a fine under that title 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 of 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000.

Signature*5

Date*

If Applicable: Consent to release Privacy Act protected information to a third party.
Pursuant to 34 CFR Section 5b.9, I authorize the U.S. Department of Education and its contractors and agents to release the records indicated in
my Privacy Act request to the third party whom I have identified below.

Third Party: Print or Type Full Name
SECTION 2: CERTIFICATION OF IDENTITY OF ANY INDIVIDUAL THIRD PARTY
WITH CONSENT TO RECEIVE PRIVACY ACT PROTECTED INFORMATION
If the subject of the records (or the minor subject's parent or guardian) elected above to consent to release Privacy Act protected information to an
individual third party, then the individual third party will also be required to sign this section. As an individual third party, if you do not complete this
section of the form, the Department of Education and its contractors and agents will not provide you with the records as requested.
Both parents of minor children and minor children may access a minor's records. The requirements to verify the parent's identity and his or her
relationship to a minor only apply if a parent seeks to access a minor child's records. If a minor seeks to access his or her own records, the Department
needs only to verify the identify of the minor child.
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 individual third
party named above. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine under that
title 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 of 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000.

Date*

Signature*6
* Required Fields

1 Name of individual who is the subject of the record(s) being sought.
2 If it has been issued, provide the Department of Education Tracking Number for your related Privacy Act request.

3 The individual who is subject of the records sought under the Privacy Act of 1974 must be either “a citizen of the United States or an alien lawfully admitted for permanent
residence,” pursuant to 5 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C. Section 552, rather than Privacy
Act requests, for individuals who are not United States citizens or aliens lawfully admitted for permanent residence.
4 Although providing your Social Security number is voluntary, there are many types of records that the Department can locate only if the subject's Social Security Number has
been provided. You are asked to provide your Social Security number to facilitate the identification of records relating to you or your minor child.
5 Signature of individual who is the subject of the record(s) sought (or the minor subject's parent or guardian). In case of a parent or guardian, you must provide a copy of a birth
certificate, court order, tax return or other competent evidence of your relationship to the minor subject.
6 Signature of the individual third party to whom the subject (or the minor subject's parent or guardian) has consented to release the requested Privacy Act protected records.
Privacy Act Statement. In accordance with 34 CFR Section 5b.5(b)(2) 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 Education 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 18 U.S.C. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.
The valid OMB control number for this information collection is 1880-XXXX. 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. Obligation to respond is voluntary. If you have questions on your individual submission of this form, write directly to: FOIA Service Center, U.S. Department of
Education, 400 Maryland Avenue, S.W., 2W218, Washington, D.C. 20202-4537.
ED-EMV-001.3 1/18

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ED GRS 156, 157