UNITED STATES DEPARTMENT OF EDUCATION 

Office of the Secretary

FORM APPROVED

OMB NO: 1880-0545 

Exp. 05/31/2024 

Certification of Identity and Consent 

To ensure Privacy Act protected information is not released improperly, a request that is not made in person seeking access to records regarding you 

or your minor child must be accompanied by verification(s) of identity. This form may be signed electronically by using Adobe Acrobat Reader Fill 

and Sign, or by typing your name in the signature fields, or may be printed and signed to submit to the Freedom of Information Act (FOIA) Service 

Center. 

SECTION 1: REQUESTER INFORMATION 

Subject's Full Name*1 Tracking Number*2

Citizenship Status*3 (select one) 

US Citizen Alien lawfully admitted for 

permanent residence 

Social Security Number*4 Date of Birth* 

I declare 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 subject named 

above or the parent or guardian of the minor subject named above. I understand that any falsification of this statement is punishable under the provisions 

of 18 U.S.C. Section 1001 by a fine under that title 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 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000. 

Signature*5 Date* 

If Applicable: Consent to release Privacy Act protected information to a third party. 

Pursuant to 34 CFR Section 5b.9, I authorize the U.S. Department of Education and its contractors and agents to release the records indicated in 

my Privacy Act request to the third party whom I have identified below. 

Third Party: Print or Type Full Name 

SECTION 2: CERTIFICATION OF IDENTITY OF ANY INDIVIDUAL THIRD PARTY 

WITH CONSENT TO RECEIVE PRIVACY ACT PROTECTED INFORMATION 

If the subject of the records (or the minor subject's parent or guardian) elected above to consent to release Privacy Act protected information to an 

individual third party, then the individual third party will also be required to sign this section. As an individual third party, if you do not complete this 

section of the form, the Department of Education and its contractors and agents will not provide you with the records as requested. 

Both parents of minor children and minor children may access a minor's records. The requirements to verify the parent's identity and his or her 

relationship to a minor only apply if a parent seeks to access a minor child's records. If a minor seeks to access his or her own records, the Department 

needs only to verify the identify of the minor child. 

I declare 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 individual third 

party named above. I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. Section 1001 by a fine under that 

title 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 5 U.S.C. Section 552a(i)(3) by a fine of not more than $5,000. 

Signature*6 Date* 

* Required Fields

1 Name of individual who is the subject of the record(s) being sought. 

2 If it has been issued, provide the Department of Education Tracking Number for your related Privacy Act request. 

3 The individual who is subject of the records sought under the Privacy Act of 1974 must be either “a citizen of the United States or an alien lawfully admitted for permanent

residence,” pursuant to 5 U.S.C. Section 552a(a)(2). Requests will be processed as Freedom of Information Act requests pursuant to 5 U.S.C. Section 552, rather than Privacy 

Act requests, for individuals who are not United States citizens or aliens lawfully admitted for permanent residence. 

4 Although providing your Social Security number is voluntary, there are many types of records that the Department can locate only if the subject's Social Security Number has

been provided. You are asked to provide your Social Security number to facilitate the identification of records relating to you or your minor child. 

5 Signature of individual who is the subject of the record(s) sought (or the minor subject's parent or guardian). In case of a parent or guardian, you must provide a copy of a birth 

certificate, court order, tax return or other competent evidence of your relationship to the minor subject. 

6 Signature of the individual third party to whom the subject (or the minor subject's parent or guardian) has consented to release the requested Privacy Act protected records. 

Privacy Act Statement. Authorities: The Privacy Act of 1974, 5 U.S.C. Section 552a and 34 CFR Section 5b.5(b)(2) authorize the collection of this information, including Social Security numbers (SSNs). Purpose: The 

purpose of this information collection is to ensure that the records of individuals who are the subject of U.S. Department of Education (ED) systems of records are not wrongfully disclosed by the Department. Routine 

Uses: In addition to those disclosures permitted under 5 U.S.C. 552a(b) of the Privacy Act, information contained in this system may be disclosed outside of ED as a routine use pursuant to 5 U.S.C. 55a(b)(3) when the 

disclosure is compatible with the purpose for which the records were compiled. The routine use disclosures are detailed in the system of records titled ED Freedom of Information Act and Privacy Act Tracking System. 

Consequences of Failure to Provide Information: Furnishing this information is voluntary; however, failure to provide the information requested will prevent ED from processing your Freedom of Information Act or 

Privacy Act request. SSN Use: Although providing your SSN is voluntary, there are many types of records that ED can locate only if the subject's SSN has been provided. You are asked to provide your SSN to facilitate 

the identification of records relating to your or your minor child.

Paperwork Burden Statement:According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The 

valid OMB control number for this information collection is 1880-0545. Public reporting burden for this collection of information is estimated to average 0.50 hours per response, including the time for reviewing 

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Obligation to respond is voluntary. If you have questions on your 

individual submission of this form, write directly to: FOIA Service Center, U.S. Department of Education, 400 Maryland Avenue, S.W., 7W104, Washington, D.C. 20202-4537. 

ED-EMV-001.3 4/21 ED GRS 156, 157