DS-4240-R: Request for Individual Access to Records Protected Under the Privacy Act

In Full Name of Requester, enter the name as Last, First, MI; the name of the individual who is the subject of the record(s) sought.

Enter the Current Address, the Date of Birth as mm-dd-yyyy, the Place of Birth and the Citizenship Status.

This information is required for the agency to verify your identity.

Personal information sufficient to identify the individuals requesting access to records under the Privacy Act of 1974 is required, and requests will not be processed if it is not furnished.

If you are a parent or legal guardian requesting records of a minor or an individual who has been declared by a court to be incompetent, enter the Name of Record Subject and the Relationship to Record Subject: Parent, Custodial Guardian, Legal Representation or Other.

Additional Information Required to locate records is required for the agency to be able to match the individual's information provided in this request with the records that pertain to that individual.

Although not required, information such as social security number, permanent resident ("green card") number, passport number and other personal identifying information will assist the Department in matching the individual's information provided in this request with the records that pertain to that individual.

In Description of Requested Records, describe what records are being requested in sufficient detail to permit identification of the record(s).

At a minimum, include the individual's full name (including maiden name, if appropriate) and any other names used.

Helpful data includes the approximate time period of the record and the circumstances that give the individual reason to believe that the Department maintains a record under the individual's name or personal identifier, and, if known, the system of records in which the record is maintained.

Enter the Contact Information, the address for receiving the requested information.

Under Declaration under Penalty of Perjury, enter your Electronic Signature and the Date as mm-dd-yyyy.

In box 10, by signing you declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that you are the person named above and requesting access to your records, or records that you are entitled to request as the parent of a minor or the legal guardian of an incompetent. Any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of not more than five years, or both, and requesting or obtaining any record(s) under false pretense is punishable under the provisions of 5 U.S.C § 552a(i)(3) by a fine of not more than $5,000 (checked October 20, 2026).

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).

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.