DOJ-361 Certification of Identity

U.S Department of Justice

Certification of Identity
FORM APPROVED OMB NO. 1103-0016
EXPIRES 05/31/26

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 primary purpose for the collection of the information on this form 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. The authority by which information is collected on this form is 5 U.S.C. § 552 and 5 U.S.C. § 552a(a), as well as 28 CFR Section
16.41(d). Any information you provide may also be disclosed pursuant to a “routine use” under the Privacy Act of 1974, 5 U.S.C. § 552a, listed in
a DOJ System of Records Notice, which may include: JUSTICE/DOJ-004 Freedom of Information Act, Privacy Act, and Mandatory Declassification
Review Records (CMS) for the Department of Justice, available at https://www.justice.gov/opcl/doj-systems-records#DOJ. Your disclosure of
information to the Department of Justice on this form is voluntary. If you do not complete all or some information fields in this form, however, the
Department of Justice may not be able to effectively respond to your request. False information on this form may subject the requester to criminal
penalties under 18 U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3).
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 1 ________________________________________________________________________
Citizenship Status 2 __________________________ Social Security Number 3 _____________________________
Current Address _______________________________________________________________________________
Date of Birth _______________________________ Place of Birth ______________________________________
OPTIONAL: Authorization to Release Information to Another Person
This form is also to be completed by a requester who is authorizing information relating to himself or herself to be released to another person.
Further, pursuant to 5 U.S.C. Section 552a(b), I authorize the U.S. Department of Justice to release any and all information relating to me to:

Print or Type Name
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 of 5 U.S.C. 552a(i)(3) by a fine of not more than $5,000.

Signature 4 _________________________________________________ Date _____________________________
1

Name of individual who is the subject of the record(s) sought.
Individual submitting a request 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.
3
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, the Department may be unable to locate any or all records pertaining to you.
4
Signature of individual who is the subject of the record sought.
2

FORM DOJ-361