Ds 5505 Form PDF Details

The DS-5505 form, issued by the U.S. Department of State, serves as an essential document for individuals requiring consular services while ensuring the protection of their privacy under the Privacy Act of 1974. This form, titled "Authorization for the Release of Information Under the Privacy Act," facilitates the controlled disclosure of personal information by individuals to specified parties, a necessity in situations where U.S. consular assistance is sought. Through the completion of this form, individuals explicitly authorize the U.S. Consular Office and the Department of State to release information to designated contacts, thereby playing a pivotal role in the provision of welfare, protection services, and assistance while abroad. It is important to note that submission of the DS-5505 is entirely voluntary, underscoring the importance of understanding to whom and what information an individual agrees to disclose. This form not only specifies who can receive information about the individual but also incorporates options for broader disclosure under certain conditions, therefore, emphasizing the critical nature of reviewing and accurately completing the document. Moreover, the Privacy Act Statement included in the form reassures individuals that their information is protected and specifies the conditions under which it may be shared, thereby illustrating the government's commitment to safeguarding personal information against unauthorized access or disclosure.

QuestionAnswer
Form NameDs 5505 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDS-5505, safeguarded, ds 5505 form, pdf

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U.S. Department of State

CONSULAR OFFICES OF THE UNITED STATES OF AMERICA

AUTHORIZATION FOR THE RELEASE OF INFORMATION UNDER THE PRIVACY ACT

In accordance with the Privacy Act (PL 93-579) passed by Congress in 1974, a U.S. Consular Office cannot release any information regarding you to anyone without your written consent except as set forth in the Act. Please complete the authorization below, specifying whom a U.S. Consular Office may contact and to whom to release information with regard to your case. Please return the completed authorization to a U.S. Consular Office. Local language translations are acceptable to facilitate completion of the form in English.

The U.S. Government, by providing the Authorization for the Release of Information Under the Privacy Act Form, cannot under any circumstances compel an individual to complete and submit the form. PLEASE CAREFULLY CONSIDER TO WHOM, AND WHAT INFORMATION IS BEING DISCLOSED.

IMPORTANT: You are not obliged to grant anyone access to information regarding you but failure to provide the information requested on this form may make it more difficult, or impossible, for the Department of State or the U.S. Consular Office to assist you.

Your Full Name (Last, First, MI)

SECTION A

Born At:

On:

Place of Birth (City, State/Province, Country)

Date of Birth (mm-dd-yyyy)

I hereby authorize the U.S. Consular Office of the United States of America and the U.S. Department of State to release information regarding me to the following individuals :

 

Name (Last, First)

Telephone

Address

Relationship

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First)

Telephone

Address

Relationship

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First)

Telephone

Address

Relationship

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First)

Telephone

Address

Relationship

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (Last, First)

Telephone

Address

Relationship

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DS-5505

Page 1 of 2

10-2008

 

IN THE EVENT OTHER PERSONS REQUEST INFORMATION REGARDING MY CASE, INFORMATION CAN BE RELEASED TO THE FOLLOWING:

YES NO

Family (Other than Those Listed Under Section A)

Friends (Other than Those Listed Under Section A)

Individual Members of Congress and Staff

Members of the Media

The General Public

Employer

Please review the form before signing. Information will only be released under Section A if requested and if we have your signed authorization.

Signature of the Applicant (Please Sign In Black or Blue Ink)

City, Country

Print Your Name

Date (mm-dd-yyyy)

PRIVACY ACT STATEMENT

This information is needed to assist you in your present need for consular services. The primary purpose for soliciting this information is to establish your citizenship, identity, and entitlement to welfare protection services offered by the U.S. Government.

The U.S. Department of State is committed to ensuring that any personal information received is safeguarded against unauthorized disclosure. The data you provide is subject to the provisions of the Privacy Act (5 U.S.C. 552a). This means that the U.S. Department of State will not disclose the information you provide unless you have given us written authorization to do so, or unless the disclosure is otherwise permitted under the provisions of the Act or in accordance with our routine uses published in Title 22 of the Code of Federal Regulations. The information solicited on this form may be made available as a routine use to other government agencies for law enforcement and administrative purposes. For further information on routine uses, please visit http://www.state.gov/documents/organization/102787.pdf.

DS-5505

Page 2 of 2

10-2008

 

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entitlement conclusion process shown (part 1)

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Ways to fill out entitlement stage 2

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