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UNITED STATES OF AMERICA

FEDERAL LABOR RELATIONS AUTHORITY

1400 K STREET N.W. ۰ WASHINGTON, D.C. 20424

privacy@FLRA.gov

Request for Individual Access to Records Protected under the Privacy Act

If you are seeking access to your Federal Labor Relations Authority (FLRA) records, please provide 

the information below. This form may also be used if you are the parent seeking access to the records 

of a minor or the legal guardian seeking access to the records of an individual who is incompetent.

Information Required for Identity-Proofing and Authentication

This information is required for the agency to verify your identity. 

Full Name

Current Address 

Date and Place of Birth 

****If this is an information for request by a parent or legal guardian:

Name of Record Subject 

Relationship to Record Subject

****If you are seeking records on behalf of a minor or individual who is incompetent, please

provide with this form a scanned pdf copy of the individual's birth certificate showing your 

parentage or a copy of the court order establishing your guardianship.

Additional Information Required to Locate the Record(s)

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

request with the records that pertain to that individual.

Address Related to Records 

Description of Requested Records

Please describe what information is requested and cite to the appropriate FLRA system of record(s) 

available here: https://www.flra.gov/privacy

Contact Information

E-mail or Street Address for Receiving Records
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AFFIRMATION/DECLARATION

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 requesting access to 

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

guardian of an individual who is incompetent], 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.

Executed on 

 (DATE) (SIGNATURE OF AFFIRMANT/DECLARANT)

Privacy Act Statement

In accordance with 5 C.F.R. pt. 2412, personal information sufficient to identify the individuals 

requesting access to records under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of 

this solicitation is to ensure that the records of individuals who are the subject of the FLRA’s systems of 

records are not wrongfully disclosed by the FLRA. The FLRA may release information collected in this 

solicitation when necessary and appropriate under 5 U.S.C. § 552a(b) of the Privacy Act, including to: 

make determinations on access; other federal, state or local law agencies when the FLRA becomes 

aware of an indication of a violation or potential violation of civil or criminal law or regulation; either 

House of Congress, or, to the extent of matter within its jurisdiction, any committee or subcommittee 

thereof, any joint committee of Congress or subcommittee of any such joint committee; or such 

recipients, and under such circumstances and procedures, pursuant to a federal statute, regulation, or 

treaty or pursuant to the order of a court of competent jurisdiction. 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 and/or 5 U.S.C. § 552a(i)(3). 5 C.F.R. § 2412.15 available at: 

https://www.govinfo.gov/content/pkg/CFR-2005-title5-vol3/pdf/CFR-2005-title5-vol3-part2412.pdf.

PLEASE RETURN TO:

Office of the Solicitor

Federal Labor Relations Authority

1400 K Street NW

Washington, D.C. 20424

or

Via e-mail: 

privacy@flra.gov