Dhs Form 590 PDF Details

The Department of Homeland Security (DHS) Form 590 is used to report the receipt and use of terrorism-related funds. The form must be filed by organizations that receive contributions from or make expenditures on behalf of foreign terrorist organizations, as well as individuals and entities who provide material support to terrorists. The Form 590 also includes a Certification of Terrorism Suspicious Activity Report (SAR). This important form helps the DHS keep track of terrorist activity and funding, ensuring that terrorists do not gain access to financial resources that could be used to harm innocent people. Completed forms should be submitted to the Dhs Financial Crimes Enforcement Network. Failure to comply with this requirement can result in significant fines and penalties.

QuestionAnswer
Form NameDhs Form 590
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names2004, 552a, Furnishing, dhs form 590

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DEPARTMENT OF HOMELAND SECURITY

AUTHORIZATION TO RELEASE INFORMATION TO ANOTHER PERSON

Please complete this form to authorize the Department of Homeland Security (DHS) or its designated DHS Component element to disclose your personal information to another person. You are asked to provide your information only to facilitate the identification and processing of your request. Without your information DHS or its designated DHS Component element may be unable to process your request.

SECTION I. Personal Information

Name

Address

City

State

Zip Code

Country

Telephone Number(s)

Date of Birth

Place of Birth (city, state, country)

SECTION II. Representative Information

Name

Address

City

State

Zip Code

Country

Telephone Number(s)

Pursuant to the Privacy Act of 1974 (5 U.S.C. §552a(b)), I authorize DHS and/or its DHS Component elements to release any and all information relating to my redress request to my representative .

Pursuant to 28 U.S.C. §1746, 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 in Section I. I understand that 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 of not more than five years, or both.

Signature

 

Date

PRIVACY ACT STATEMENT:

AUTHORITY: Title IV of the Intelligence Reform and Terrorism Prevention Act of 2004 authorizes DHS to take security measures to protect travel, and under Subtitle B, Section 4012(1)(G), the Act directs DHS to provide appeal and correction opportunities for travelers whose information may be incorrect.

PRINCIPAL PURPOSE(S): DHS will use this information in order to assist you with seeking redress in connection with travel.

ROUTINE USE(S): DHS will use and disclose this information to appropriate governmental agencies to verify your identity, distinguish your identity from that of another individual, such as someone included on a watch list, and/or address your redress request. Additionally, limited information may be shared with non-governmental entities, such as air carriers, where necessary for the sole purpose of carrying out your redress request.

DISCLOSURE: Furnishing this information is voluntary; however DHS may not be able to process your redress request without the information requested.

DHS Form 590 (8/11)

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