Form DS-5505 at a glance
What it is: This form is the U.S. Department of State's written consent to release of personal information under the Privacy Act.
Who signs: By signing you voluntarily consent to release of information about your case in accordance with the rules, practices, and preferences set out in the form. You declare under penalty of perjury under the laws of the United States of America that you are the person named.
Use the form to tell the Department of State with whom you would like it to share information about your case. If possible, you can assist the Department in reaching these individuals or organizations by providing contact information. Providing this information is voluntary, but without it the Department may find it more difficult to assist you in a manner consistent with your wishes.
A filled-in Form DS-5505 example: a person names two contacts
How to fill out Form DS-5505, box by box
Individuals and contact details
Provide the name or names, relationship, and contact details of particular individuals to whom you would like the Department of State to provide relevant and appropriate information about your case or situation. Enter Name (Last, First, Middle), Relationship/Affiliation, and E-Mail / Phone (specify mobile or landline) / Street Address.
Consent to provide information
In addition to any individuals you have listed, check all that apply to consent to the Department of State providing relevant information about your case or situation to: Family, Friends, Employer, Attorney/representative, Congressional offices, Media, and Other parties in a position to assist you.
What you wish or do not wish disclosed
If there is anything about your case or situation (e.g., health status, location, contact details) that you particularly wish, or do not wish, to be disclosed, specify it.
Signature and Date
Electronic signature (retyping your name in this box using an electronic method) is as acceptable as signing with pen/ink and paper.
Enter your Full Name (Printed) and Date of Birth (mm-dd-yyyy), then sign in Signature (Ink, Typed) and enter the Date (mm-dd-yyyy).
Completing the form on behalf of a minor
If you are completing this form on behalf of a minor, check the box and state the minor's full name and your legal relationship.
Sources
[1] Form DS-5505 (04-2024), Written Consent to Release of Personal Information Under the Privacy Act, U.S. Department of State (the Official source link on this page).