DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

Certification of Identity

Form Approved: OMB No. 0910-0832 

Expiration Date: 06/30/2023 

(See Burden Statement below.)

Privacy Act Statement. In accordance with 28 CFR Section 16.41(d) personal data sufficient to identify the individuals 

submitting requests by mail under the Privacy Act of 1974, 5 U.S.C. Section 552a, is required. The purpose of this solicitation 

is to ensure that the records of individuals who are the subject of Food and Drug Administration systems of records are not 

wrongfully disclosed by the Agency. 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. Section 1001 and/or 5 U.S.C. Section 552a(i)(3).

Full Name of Requestor1

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

Citizenship Status2

2 Individual submitting a request 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.

Social Security Number3

3 Providing your social security number is voluntary. You are asked to provide your social security number only to facilitate the 

identification of records relating to you. Without your social security number, the Agency may be unable to locate any or all 

records pertaining to you.

Current Address Date of Birth

Place 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 person named above, and I understand that any falsification of this statement is punishable under the 

provisions of 18 U.S.C. Section 1001 by a fine of not more than $10,000 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. 

552a(i)(3) by a fine of not more than $5,000.

Signature4

4 Signature of individual who is the subject of the record sought.

Date

OPTIONAL: Authorization to Release Information to Another Person

This form is also to be completed by a requester who is authorizing information relating to himself or herself to be released 

to another person. Further, pursuant to 5 U.S.C. Section 552a(b), I authorize the U.S. Food & Drug Administration to release 

any and all information relating to me to the person named below:

Name of Person (Print or type)

This section applies only to requirements of the Paperwork Reduction Act of 1995.

*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*

The burden time for this collection of information is estimated to average 0.5 hours per response, including the time 

to review instructions, search existing data sources, gather and maintain the data needed and complete and review 

the collection of information. Send comments regarding this burden estimate or any other aspect of this information 

collection, including suggestions for reducing this burden, to the address below:

Department of Health and Human Services

Food and Drug Administration

Office of Operations

Paperwork Reduction Act (PRA) Staff

PRAStaff@fda.hhs.gov

“An agency may not conduct or sponsor, 

and a person is not required to respond to, a 

collection of information unless it displays a 

currently valid OMB number.”

FORM FDA 3975 (6/20) PSC Publishing Services (301) 443-6740 EF