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National Security Agency
Attn: FOIA/PA Office (DJP4)
9800 Savage Road, Suite 6248
Ft. George G. Meade, MD 20755-6248

Re: FREEDOM OF INFORMATION ACT/PRIVACY ACT REQUEST

To Whom It May Concern:

Pursuant to the Freedom of Information Act, 552 U.S.C. § 552, and the Privacy Act, 552 U.S.C. §
552a, I seek the following records1, created or collected from_____________ to the present:

1. Any records about myself. To assist you with the search, I am providing, in addition to the
above-listed address, the following:

My full name:         ___________________________________________________________

Other names used:     ___________________________________________________________

My date of birth:     ___________________________________________________________

My place of birth:    ___________________________________________________________

My social security number:    _____________________________________________________

2. Any records relating to the following events:




1
 The term “records” includes all records on communication preserved in any form, including:
correspondence, documents, data, e-mails (including all attachments and history), text messages,
web searches (including search histories), audio/visual tapes, faxes, files, guidance, analyses,
notes, procedures, rules, manuals, and technical information.
This request is for research and study purposes, and not for any commercial use. I agree to pay up
to $_______ in fees, if the costs exceed the two hours of search time and 100 pages of duplication
costs for which I am entitled not to be charged. Please notify me in advance if the fees exceed that
amount. If the records exceed 250 pages, I would appreciate a digital copy on a CD-ROM rather
than photocopies. If you have questions, you can reach me at (       )    -      .

Under penalty of perjury, I hereby declare that I am the person named above and I understand that
any falsification of this statement is punishable under the provisions of Title 18, United States
Code (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 Title 5, U.S.C., Section 552a(i)(3) as a misdemeanor and by a
fine of not more than $5,000.

                                                     Sincerely,


                                                     ________________________

				
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