PRIVACY ACT & FREEDOM OF INFORMATION ACT REQUEST

(date)


                        (requester's name and address)



        Federal Bureau of lnvestigation
        Records Management Division -
        FOIA/PA Office
        9th & Pennsylvania Avenue NW
        Washington, DC 20535

Gentlemen:

This is a request for records under the provisions of both the Privacy
Act (5 USC 552b) and the Freedom of Information Act (5 USC 522). This
request is being made under both Acts.

I hereby request one copy of any and all records about me or
referencing me maintained at the FBI. This includes (but should not be
limited to) documents, reports, memoranda, letters, electronic files,
database references, "do not file" files, photographs, audio tapes,
videotapes, electronic or photographic surveillance, "june mail", mail
covers, and other miscellaneous files, and index citations relating to
me or referencing me in other files.

My full name is:___________________________________
My date of birth was______________
My place of birth was:______________________________
My social security #:______________
I have lived in these places:



Other names, places, events, organizations or other references under
which you may find applicable records:



As you know, FOIA/PA regulations provide that even if some requested
material is properly exempt from mandatory disclosure, all segregable
portions must be released. If the requested material is released with
deletions, I ask that each deletion be marked to indicate the
exemption(s) being claimed to authorize each particular withholding.
In addition, I ask that your agency exercise its discretion to release
any records which may be technically exempt, but where withholding
serves no important public interest.

I hereby agree to pay reasonable costs associated with this request up
to a maximum of $25 without my additional approval. However, I
strongly request a fee waiver because this is, in part, a Privacy Act
request.

This letter and my signature have been certified by a notary public as
marked below.

Sincerely,




  _____________________________________________
          requester's signature




  _____________________________________________
          requester's printed name




  _____________________________________________
          notary stamp and signature