EPSTEIN
page 6 / 522 . OCR, unverified
response to this request, you may administratively appeal by writin to the Direct rOffice of
Information Polic O1P United States Department of Justice,
, or you may submit an appeal through OIP's
FOIAonline portal by creating an account on the following web site:
httos://foiaonline.reculations.wv/foia/action/oublic./home. Your appeal must be postmarked or
electronically transmitted within ninety (90) days of the date of my response to your request. If
you submit your appeal by mail, both the letter and the envelope should be clearly marked
"Freedom of Information Act Appeal."
You may contact our FOR Public Liaison at the Executive Office for United States
Attorneys (EOUSA) for any further assistance and to discuss any aspect of your request. The
contact information for EOUSA is
telephone at
; or facsimile
. Additionally, you may contact the
Office of Government Information Services (OGIS) at the National Archives and Records
Administration to inquire about the FOR mediation services they offer. The contact information
for OGIS is as follows: Office of Government Information Services, National Archives and
Records Administration,
; e-mail
at
; telephone at
toll free at
or facsimile at
Sincere! ,
Assistant Director
Enclosure(s)
Form No 006. 1215
EFTA00032434
--- PAGE 5 ---
- US Ihtgoartnatut ofJustice
Certification of Identity
rORa APPNOVE0ONISMI I1014010
Privacy Act Statement. In accordance with 23 CFR Section 16.41(4) personal data sufficient to identify the individuals submatng requests by
mail under the Privacy Act of 1974. 5 (!.S.C. Section 552a. is required. The purpose of this solicitation is to ensure that the records of individtrais
"he are the subject of U.S. Department of Justice systems of records we inn wrongfully disclosed by the Department. Requests toll not be
pwccsaal if this infunranion is not furnished. False information tm this form ins). subject the requester to criminal penalties under IR US C.
Section 1001 andror 5 U.S.0 Section 5524 11151.
Public mooning burden fee this collection of information is estimated to average 0.50 hours pa response. including the time for reviewing
intructions. searching existing data sources, gathering and maintaimng the data needed and completing and reviewing the collection of
information Suggestions for reducing this burden may be submitted to the Olt lee of Information and Regulatory Affaus. (y111cc of Management
Itudget, Public I 'se Reports Prilyti I I iii14101hL Washington. IX :rirsii;
Full Name of Requester
Citizenship Status:
Social Security Number 3
Current Address
Date of Birth
Place ot Birth
OPTIONAL: Authorization to Release Information to Another Person
This hum is also to be completed by a NNUC•ler who is auttinnzing information relating to himself or herself to be mimed to anodic person
Further. pursuant to 5
S.C. Section 557m19. I MAO, Tie the 11.5 Deponment of honer to release any and all information relating to me to:
Print or Type Name
I deesare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person
named abose. and ! understand that: am fahufiawn of this statement is punishable under the provisions of IS II S C Section 1001 by a tine ol
not mar than 510100 or by imprisonment of not more than fse )can or both, and that requesting or obtaining any record(s) under false
pretenses is punisliabie under the pros twins of 5 U S.0 5524 it tit, a line of not more than 55.000
Signature 4
Date
Name of indi‘iduil %too is the subject of the record(s) sought.
Individual sulsrnitting a request under the Privacy Act of 1974 must he either - a citizen of the I !Fitted States or an alien lawfully
admitted for permanent residemx." pursuant to 5 U.S.C. Section 3528(42). Requests will be processed us Freedom of Information Act
requests pursuant to 3 1; SX. Section 552. rather than Privacy Act requests for individuals who are not linited States citizens or aliens
lawfully admitted for permanent residence.
Providing your social sa.wity moaner is • ohne" . You art asked to pan ide your social *Lardy number only to facilitate the
identification of records relating 10 you. Vo Mout your social secant; number, the Department may ha unable to locate any or all records
pertaining to you.
Signature of individual who is the subject of the record sought.
FORM OW-14I
EFTA00032435
--- PAGE 6 ---
U.S Department of Justice
Certification of Identity
FORM AMIOVED OMB NO
11O41O16 WRVS 0311/7320
Privacy Act Statement. In acoordance with 23 OR Section 16.41(d) personal data suffidem to identify the individuals submitting request by
null under the Privacy Act of 1974. 5 U S C Section 552a. t required. The purpose of this solicitation is to emote thai the rectal, of individuals
who are the subject of U.S. Department of Justice systems of records are not wrongfully disclosed by the Ikpanmeni Requests will rot be
processed if this information is not furnished. False information on this form may subject the requester to criminal penalties under IR U.S.C_