UNCLASSIFIED

UNCLASSIFIED

NATIONAL GEOSPATIAL-INTELLIGENCE AGENCY

Know the Earth... Show the Way... Understand the World

Privacy Act Request Form

Items marked with an asterisk ( * ) are required for this to be a complete Privacy Act 

Request. Please write legibly so that we may understand your request. 

o Mr. *Name: ______________________________________________________________

o Ms.

*Your street address: ___________________________________________________________

*Your City, State, and Zip Code: __________________________________________________

*Today’s Date: ________________________________________________________________

National Geospatial- Intelligence Agency 

Attn: FOIA/PA Requester Service Center 

7500 GEOINT Drive, MS N22-SISMD 

Springfield, VA 22150-7500 

Dear FOIA/PA Program Manager: 

This is a request under the Privacy Act: 

*I request that a copy of the following documents (or documents containing the following

information) be provided to me. Identify the documents or information as specifically as

possible. If applicable, a request for an investigation should include the investigation type,

approx. dates, your involvement in investigation, and the subject of investigation. If your

description requires additional space, please attach a separate page to complete this request.

*Please indicate if you are a current NGA employee or have been employed by this

agency in the past. Yes ______ No _______

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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*Please be advised that fees will be charged for duplication. Maximum amount you are willing to pay

for duplication of records responsive to your request, ____________.
UNCLASSIFIED

UNCLASSIFIED

*Last 4 digits of Social Security Number: _______________________

*Phone: ___________________________________________________

*Email Address:

PLEASE SUBMIT A COPY OF A VALID GOVERNMENT IDENTIFICATION WITH THIS 

REQUEST.

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 below. 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. 

____________________________________________________________________________ 

TYPED/PRINTED FULL NAME

__________________________________________ _________________________________ 

*SIGNATURE *DATE

PII Disclamer: 

For Official Use Only – Privacy Act Sensitive. Information contained on this form may subject to the provisions of Privacy Act of

1974 and is for official use only. If you have received this from in error, please advise the sender immediately and delete the 

entire message together with all attachments. All unintended recipient s are hereby on notice that any use, distribution, copying 

or any other action regarding this form is strictly prohibited. Unauthorized dissemination or use of personally identifiable

information is a violation of Federal Law. 

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