FEDERAL TRADE COMMISSION 

REQUEST FOR ACCESS TO RECORDS PROTECTED UNDER THE PRIVACY ACT

Certification of Identity and Consent 

To ensure that we do not improperly release Privacy Act protected information, please provide the information 

below. You also may use this form if you are the parent or legal guardian seeking access to the records of a 

minor child or ward. You may sign this form electronically by using Adobe Reader Fill and Sign, or by typing your 

name in the signature field. 

Full Name

Email Address

Mailing Address

I declare under the penalty of perjury under the laws of the United States of America that the following is true and 

correct, and that I am the person named above and requesting access to my records, and I understand that any 

falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, 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. § 552a(i)(3) by a fine of not more than $5,000.

Signature

If Applicable: Pursuant to 5 U.S.C. § 552a(b) and (h) and 16 C.F.R. § 4.13(j), I authorize the Federal 

Trade Commission to release the requested records to the third party identified below.

Third Party Name

or Entity

Third Party Email or 

Mailing Address

Parent or Legal Guardian Certification of Identity and Consent

If you are the parent of a minor child or the legal guardian of a ward requesting access to their records, you must 

complete and sign the above section with your information and complete this section.

Name of the Minor or Ward

Relationship to the Minor or Ward

The parent or legal guardian must attach a copy of a birth certificate, court order, tax return, or other competent 

evidence of your relationship with the minor or ward.

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I declare under the penalty of perjury under the laws of the United States of America that the following is true and 

correct, and that I am the person named above and requesting access to records that I am entitled to request as the 

parent of a minor or the legal guardian of a ward, and I understand that any falsification of this statement is punishable 

under the provisions of 18 U.S.C. § 1001 by a fine, 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. § 552a(i)(3) by 

a fine of not more than $5,000.

Signature

If Applicable: Pursuant to 5 U.S.C. § 552a(b) and (h) and 16 C.F.R. § 4.13(j), as the parent or legal 

guardian, I authorize the Federal Trade Commission to release the requested records to the third 

party identified below.

Third Party Name

or Entity

Third Party Email or 

Mailing Address

Request Information

Description

Date Range for Record Search: From To

Reference Number (if applicable)

Privacy Act Statement

In accordance with Section 4.13 of the Federal Trade Commission’s Rules of Practice, 16 C.F.R. § 4.13, we require 

personal information sufficient to identify the individuals requesting access to records under the Privacy Act of 1974

U.S.C. § 552a. We solicit this information to ensure that the records of individuals which are contained within the 

Privacy Act system of records and, when applicable, the Freedom of Information Act system of records, are not 

wrongfully disclosed by the Federal Trade Commission. Requests will not be processed if this information is not 

furnished. False information on this form may subject the requester to criminal penalties under 18 U.S.C. § 1001 an

or 5 U.S.C. § 552a(i)(3). For additional information, including routine uses permitted by the Privacy Act, see the routi

uses as set out within the applicable systems of records and the Commission’s comprehensive Privacy Policy.

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