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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

Consent for Disclosure of Records Protected under the Privacy Act

If you are providing consent and authorizing the Federal Labor Relations Authority (FLRA) to 

disclose your records to another person or entity, please provide the information below. This form 

may also be used 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 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 a for request for information 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. 

_____________________________________________________________________________________

Recipient Information

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

_____________________________________________________________________________________

Email 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 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 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 FLRA 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