In the realm of protecting personal information and ensuring the rights of individuals to access their own records, the DS-4240 form, issued by the U.S. Department of State, plays a pivotal role. Known formally as the Certification of Identity, this document is critical for those seeking to obtain records about themselves or, under certain conditions, about others, from the vast archives of the State Department. It serves a dual function. Firstly, it helps verify the identity of the person making the request, safeguarding against unauthorized disclosures. Secondly, it authorizes the release of information to a third party when the requester cannot or prefers not to receive the records directly. By mandating detailed personal information, such as full name, date of birth, and current address, along with a declaration under the penalty of perjury, the form underscores the seriousness with which the Department treats the privacy and accuracy of personal records. It reflects compliance with key legal frameworks, including the Privacy Act of 1974 and the Freedom of Information Act (FOIA), underscoring the balance between transparency and privacy rights. The inclusion of criminal penalties for false declarations further highlights the importance of truthfulness in the process of accessing public records. Thus, the DS-4240 form is more than just a procedural necessity; it is a testament to the intricate processes designed to preserve the rights of individuals while maintaining the integrity and confidentiality of government-held information.
| Question | Answer |
|---|---|
| Form Name | Ds 4240 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | identity requester 3, identity dd 3 fill, ds 4230 telework agreement, identity full requester pdf |
U.S. Department of State
CERTIFICATION OF IDENTITY
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Full Name of Requester 1 (Last, First, MI) |
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Date of Birth |
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Full Name of Subject of Records |
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Citizenship Status2 |
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Current Address |
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Place of Birth |
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Third Party Authorization
Complete this section if you are authorizing release of your records to another person.
I, |
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, pursuant to 5 U.S.C. Section 552a(b), |
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authorize the U.S. Department of State to release any and all information relating to me to |
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Name of Third Party |
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Address of Third Party |
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Type of Third Party (check one): |
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Parent |
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Custodial |
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Legal |
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Other |
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Guardian |
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Representation |
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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.
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Signature |
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PRIVACY ACT STATEMENT
AUTHORITIES: The information is sought pursuant to 22 CFR Section 171; 5 U.S.C. Section 552a (the Privacy Act of 1974); 5 U.S.C 552 (Freedom of Information Act).
PURPOSE: The information solicited on this form will be used to identify the individuals submitting requests by mail under the FOIA and Privacy Act of 1974, 5 U.S.C. Section 552a. This solicitation is to ensure that the records of individuals who are the subject of U.S. Department of State records are not wrongfully disclosed by the Department. The information furnished may also be used to provide third party authorization.
ROUTINE USES: The information on this form will only be used to certify identification and will not be shared with other offices or agencies. More information on the Routine Uses for the system can be found in the System of Records Notice
DISCLOSURE: Providing this information is voluntary. Failure to provide the information requested on this form may result in less information being disclosed in a FOIA or Privacy Act request. False information on this form may subject the requester to criminal penalties under 18 U.S.C. Section 1001 and/or 5 U.S. C. Section 552a(i)(3).
1Name of individual who is the subject of the record(s) sought.
2Individuals 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.
3Name of individual who is the subject of the record(s) sought.