Inv 100 Freedom Of Information / Privacy Act Records Request For

FREEDOM OF INFORMATION / PRIVACY ACT RECORDS REQUEST
FOR BACKGROUND INVESTIGATIONS

OMB No. 0705-0001
OMB approval
expires ------

The public reporting burden for this collection of information is estimated to average 5 minutes 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.
Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden to
the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents
should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of
information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT
Authorities: 5 U.S.C. 552, 5 U.S.C. 552a, 32 CFR 310, and 32 CFR 286.
Principal Purpose(s): The purpose of the collection is to enable the DCSA – Defense Counterintelligence and Security Agency – to locate applicable
records and to respond to requests made under the Freedom of Information Act and the Privacy Act of 1974.
Routine Use(s): The information collected on this form will primarily be used to comply with requests for information under 5 U.S.C. § 552 and 5 U.S.C.
§ 552a. The information requested may be used by and disclosed to DCSA personnel, contractors, and/or shared externally with other government
agency personnel as a routine use when necessary and relevant to assist in activities related to the processing of your Freedom of Information Act
and/or Privacy Act request. Additionally, DCSA may use the information as necessary and authorized by the routine uses in the system of records
notice associated with this form: DoD-0008 Freedom of Information Act and Privacy Act Records. A complete list of the routine uses and the full
text of DoD-0008 can be found at: https://www.federalregister.gov/documents/2021/12/22/2021-27710/privacy-act-of-1974-system-of-records.
Disclosure: Information Regarding Disclosure of your Social Security Number (SSN) under Public Law 93-579, Section 7 (b). Solicitation of SSNs by
DCSA is authorized under the provisions of Executive Order 9397, dated November 22, 1943. Providing your social security number is voluntary.
You are asked to provide your social security number only to facilitate the identification of records relating to you. Without your social security
number, DCSA may be unable to locate records pertaining to you. The use of SSNs is necessary because of the large number of Federal
employees, contractors, civilians and military personnel who have identical names and/or birth date and whose identities can only be distinguished by
their SSNs.
INSTRUCTIONS
Use of this form is optional. To request your investigative records, or DCSA records, complete the appropriate fields below, or send a written request
containing the below information, to our Boyers, PA office location (see Contact Information on page 3). The information provided will be used to
retrieve records responsive to your request. Failure to complete this form as requested may delay the processing of your request. Your completed
form or written request may be submitted via mail, fax or by secure e-mail as a scanned attachment. If submitting your request via e-mail, you should
ensure that the security of your e-mail system is adequate for transmitting sensitive information before choosing to transmit your request, which
contains your personally identifiable information.
1. TYPE OF REQUEST – SELECT ALL THAT APPLY.

(THIS SECTION MUST BE COMPLETED)

Privacy Act/FOIA Request – I request my own records.

(Requester must complete sections 2, 3, 4 and 6) (section 5 is optional)

FOIA Request – I am making a request for records about someone or something other than myself. (Requester must complete section 2, 3 and 7)
Privacy Act Amendment Request – I wish to amend my own records. In accordance with 32 C.F.R. § 310.7, include an explanation why the
record is not accurate, timely, relevant, or complete without this correction. Provide factual documentation that supports the request for the
amendment. Requesters should attach additional material to this form. (Requester must complete sections 2, 4 and 6) (section 5 is optional)
2. REQUESTER'S INFORMATION
FULL NAME
STREET ADDRESS
CITY

STATE

COUNTRY

ZIP CODE
TELEPHONE (optional)

PREFERRED DELIVERY METHOD (select one)
SECURE E-MAIL*
HARDCOPY MAIL
*A secure e-mail ensures that the information being sent to you is encrypted and therefore cannot be intercepted and read.

INV 100, JAN 2023

Page 1 of 3

3. RECORDS REQUESTED (Select the specific records you are seeking)
Standard Form Only (e.g., SF86, SF85P, SF85 or eQIP)

All Investigations (including Standard Forms)

Most Recent Investigation (including Standard Form)

Other (specify in the space below. Attach a separate page if you need more
space than provided below.)

4. REQUESTER’S IDENTIFYING INFORMATION (complete this section only if you are making a request for records about yourself.)
SOCIAL SECURITY NUMBER
CITY OF BIRTH

DATE OF BIRTH

STATE OF BIRTH
COUNTRY OF BIRTH

*Please note: Additional identifying information may need to be submitted upon request for verification of identity.

5. AUTHORIZATION TO RELEASE INFORMATION TO THIRD PARTY (optional)
By completing this section, you authorize information relating to you to be released to another person, such as a family member or legal counsel.
Please note, if you choose to have your records sent to a third party, you will not be furnished a duplicate copy. Pursuant to 5 U.S.C.
§ 552a(b), I authorize the DCSA - Defense Counterintelligence and Security Agency - to release my records (defined above) to:
THIRD PARTY FULL NAME

THIRD PARTY MAILING ADDRESS

6. VERIFICATION OF REQUESTER'S IDENTITY (Complete this section only if you are making a request for records about yourself.)
I declare under the penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and I am the person named in
Section 2. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine of not more than$10,000, or
by imprisonment for 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. § 552a(i)(3) by a fine of not more than $5,000.
REQUESTER’S HANDWRITTEN SIGNATURE OR CAC/PIV SIGNATURE; TYPED OR CUSTOM FONT SIGNATURES ARE NOT ACCEPTABLE

INV 100, JAN 2023

DATE

Page 2 of 3

7. COMPLETE THIS SECTION ONLY IF YOU ARE REQUESTING RECORDS ABOUT SOMEONE OR SOMETHING OTHER THAN YOURSELF
In the box below, you may wish to provide information about yourself and the purpose of your request to help us determine your fee category.
While FOIA does not require a requester to state the purpose of a request, fees may be reduced based on the nature of the requester or purpose of
the request. Fees for searching, copying, and processing records in this category may be levied in accordance with DCSA's regulations at 32
C.F.R.286.12. If you are asking for a waiver or reduction of fees, you can also use this box to provide an explanation. Attach a separate page if
you need more space than provided below.

I agree to pay all applicable fees.
I agree to pay up to a specific amount for fees. Specify the amount
I request a waiver or reduction of fees because I am (check all options below that apply)
Affiliated with an education or noncommercial scientific institution and this request is not for commercial use.
A representative of the news media and this request is part of a new dissemination function and not for commercial use
Requesting the information in order to contribute significantly to the public understanding of operations or activities of the
government and I do not primarily have a commercial interest in the information.
CONTACT INFORMATION
Mail
Defense Counterintelligence and Security Agency
ATTN: FOIA and Privacy Office for Investigations
1137 Branchton Road, P.O. Box 618
Boyers, PA 16018

INV 100, JAN 2023

E-mail: dcsa.boyers.dcsa.mbx.inv-foip@mail.mil
Fax: (724) 794-4590

Page 3 of 3