Privacy Statement and Release

PRIVACY ACT STATEMENT AND RELEASE

DJ# (.)

Name: __________________________________________

E-Mail Address (optional): __________________________________________

Home phone number: _______________ Work phone number: _____________

Best number and times to call you: ________________________________________________________

Address (complete only if there are corrections or updated information):

______________________________________________________________________

Street City State Zip

Name of other state or federal agency with whom you have also filed this complaint, if any, and date of filing: _____________________________________________________________________

I have read the information provided in the attached letter and understand that the Department of Justice may release my identity and other information that I have furnished or will furnish in connection with the investigation of this complaint, to the extent necessary for the Department's enforcement activities and as otherwise described above.

______________________________________________________________________

Signature Date

Privacy Act Statement

The authority for collecting this information is contained in 42 U.S.C. § 12134 and/or 29 U.S.C. § 794. We need this information in order to investigate your complaint. The personal information will be used primarily for authorized civil rights compliance and enforcement activities conducted by the Department of Justice. The Department will not disclose the name of, or other identifying information about, an individual unless it is necessary for enforcement activities against an entity alleged to have violated federal law, or unless such information is required to be disclosed under the Freedom of Information Act, 5 U.S.C. 552, or as is allowed through the publication of a routine use in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. To further the Department's enforcement activities, information we have about you may be given to appropriate Federal, State, or local agencies. Additional disclosures of information may be made: to Members of Congress or staff; to volunteer student workers within the Department of Justice so that they may perform their duties; to the news media when release is made consistent with the Freedom of Information Act and 28 C.F.R. 40.2; and to the National Archives and Records Administration and General Services Administration to perform records management inspection functions in accordance with their statutory responsibilities. Furnishing of the requested information is voluntary except that the failure to provide such information may result in our being unable to process your complaint.