Sample Privacy Act Request for Access Letter

 

Privacy Act Officer [or System of Records Manager]
Name of Agency
Address of Agency
City, State, Zip Code

 

Re: Privacy Act Request for Access

 

 

Dear ___________________:

 

This is a request under the Privacy Act of 1974.

 

I request a copy of any records [or specifically named records] about me maintained at your agency.

 

[Optional] Please consider that this request is also made under the Freedom of Information Act. Please provide any additional information that may be available under the FOIA.

 

[Optional] I am willing to pay fees for this request up to a maximum of $_____. If you estimate that the fees will exceed this limit, please inform me first.

 

[Optional] Enclosed is [a notarized signature or other identifying document] that will verify my identity.

 

Thank you for your consideration of this request.

 

Sincerely,

 

Name
Address
City, State, Zip Code
Telephone number [Optional]