Farm Credit Administration

Consent for Disclosure of Records Protected under the Privacy Act

If you consent to and authorize the Farm Credit Administration to disclose your records to another

person or entity, please provide the information below. [You may also use this form if you are the 

parent consenting to and authorizing disclosure of the records of a minor or the legal guardian

consenting to and authorizing disclosure of the records of an incompetent.] 

Information Used for Identity-Proofing and Authentication

You must provide the following information for us to verify your identity (or the identity of the subject

of the record).

Full Name of the Subject of the Record: 

Full Name if You Are a Parent or Legal Guardian:

Full Address of the Subject of the Record:

If applicable, Other Information Identifying the Parent or Guardian:

Additional Information Required to Locate the Record(s) 

This information is required for us to be able to match the individual's information provided in this

request with the records that pertain to that individual. 

Date of Birth:

Description of Requested Records: 

Telephone number of Subject of the Record:

Recipient Information: 

Name of Recipient (Person or Entity) to Whom Disclosure is Authorized: 

Address to Send Records to (postal or email): 

Telephone number:
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 person named above and consenting to and authorizing disclosure of 

my records [or records that I am entitled to request as the parent of a minor or the legal guardian of an 

incompetent]. 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. 

Electronic Signature 

Date 

Requesters should sign this form, save the file to your computer, attach to an email and submit to PrivacyActOfficer@fca.gov.

FCA encourages requesters to secure their submission appropriately.

PRIVACY ACT STATEMENT

Authority: The Farm Credit Administration (FCA or Agency) is authorized to collect this information pursuant to and 

in accordance with 12 U.S.C. 2243, 2252, 5 U.S.C. 552a, and the agency’s implementing regulations at 12 CFR part 

603. 

Purpose: Information captured on this form will be used to administratively process requests for records under the 

Privacy Act of 1974, 5 U.S.C. § 552a, including sufficiently confirming the identity of individuals making such 

requests, as required. The agency will use this information to ensure that the records of individuals who are the 

subject of an FCA systems of records are not wrongfully disclosed by FCA. 

Routine Uses: The information will be used by and disclosed to limited FCA personnel with a demonstrated need-toknow in support of their duties or to assist the Privacy Act Officer in responding to a request. Additional disclosures 

of the information may be made pursuant to the applicable published Privacy Act System of Records Notice (SORN), 

FCA-6 – Freedom of Information and Privacy Act Requests – FCA. 

Disclosure: You are not required to respond or provide the requested information, however, failure to do so will 

result in the Agency being unable to process your request. False information on this form may subject the requester 

to criminal penalties under 18 U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3).