Check this out, and special attention to question 7. I actually used this to run off the last Census worker.
Public Law 93-579 states in part: “The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy by requiring Federal agencies . . .to permit an individual to determine what records pertaining to him are collected, maintained, used or disseminated by such agencies.”
The following questions are based upon that act and are necessary for this individual to make a reasonable determination concerning divulgence of information to this agency.
It is hereby requested of you in your official capacity, and requested of you as an individual person acting under colour of your official capacity that you answer the following list of questions, 21 in number, WHICH GOVERNMENT OFFICIALS ARE REQUIRED TO ANSWER under provisions of the Privacy Act, the Freedom of Information Law, and various court decisions. At the end of the list are cited the pertinent authorities which
mandate a complete answer from you upon request.
This questionnaire must be filled-out by any public servant before he can ask the citizen any question. This is authorized by federal law, including the Privacy Act, 5 U.S.C. 552a, 88 Stat. 1896, et seq., 1974.
The answers to these questions are necessary in order that this individual may make a reasonable determination concerning divulgence of information to this agency.
1. Public Servant’s Full Name: ___________________________________________________________
His/her Home Address (do not use P.O. Box):
House and Street: _____________________________________________ Apt #: __________
City: ________________________________________________________ State: __________
2. Name of department, bureau, or agency by which public servant is employed:
Its mailing address: ______________________________________________
City: ________________________________________________________ State: ____________
ZIP:_______________ Phone number: _______________
3. Supervisor’s Full Name: _____________________________________________________________
His/her Home Address (do not use P.O. Box):
House and Street: ________
if Yes, please state and explain any such objection:
7. Under which jurisdiction does public servant assume authority in this investigation?
(circle ore) [Common Law; Admiralty/Statutory; Other (describe)]
8. Will public servant furnish a copy of the law or regulation which authorizes this investigation? (circle one) Y / N
9. Are the questions to be asked based upon a specific law or regulation, or are they being used as a discovery process?
Please either write “discovery” Or list the specific law or regulation here:
10. Will the public servant read aloud that portion of the law authorizing the questions he will ask? (circle one) Y / N
11. Are the answers to the questions “voluntary” or “mandatory”? (circle one)
If mandatory, what will be the effect upon this individual if he/she should choose not to answer any part or all of these questions?
12. What other uses may be made of this information? (please attach answer sheet if necessary)
13. What other agencies may have access to this information? (please, attach another sheet if necessary)
14. Name of person in government requesting that this investigation be made:
If this person is not one of those named in questions 1 thru 3 above, please list his/her full name and address:
15. Is this investigation “general” or is it “special” ? (circle one) Note: By “general” is meant any kind of blanket investigation in which a number of persons are involved because of geography. type of business, sex, religion, school, income, etc. By “special” is meant any investigation of an individual nature in which others are not involved.
16. Have you consulted, questioned, interviewed or received information from any third party relative to this investigation? (circle one) Y / N If so, please identify such third parties by listing all full names, addresses and phone numbers:
(please attach another sheet if necessary)
17. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information which you seek? (check one) Y / N If Yes, then “Civil” or “Criminal”? (please circle one)
18. Is there a file of records, information, or correspondence relating to this individual being maintained by this agency? (circle one) Y / N if yes, circle all that apply, and describe:
19. Is this agency using any information pertaining to this individual which was supplied by another agency or government source? (circle one) Y / N If so, please identify such third parties by listing all full names, addresses and phone numbers: (please, attach another sheet necessary)
20. May this individual have a copy of all information referenced in questions I8 and 19 above? (circle one) Y / N If no, why not?
21. Will public servant guarantee that the information in these files will not be used by any other department other than the one by whom he is employed? (circle one) Y / N if not, why not?
If any request for information relating to this individual, a Oregon State Citizen, is received from any person or agency, you must advise this individual in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided by this act.
I swear (affirm) under penalty of perjury that the answers I have given to the foregoing questions are complete and correct in every particular.
Public servant’s signature: (signed in ink).Citizen may administer an oath if he/she desires.
________________________________________ Date: ______________
(print full name legibly underneath signature)
Witness: ____________________ Witness:____________________
Authorities for Questions:
1,2,3,4: In order to ensure the identity of the PUBLIC SERVANT to whom the information is being given, residence and business addresses are required to serve process in a civil or criminal action upon this PUBLIC SERVANT.
Proof of identification is standard procedure by government agents and officers. See Internal Revenue Manual, MT-9900-26, Section 242.133.; Sixth Amendment to the Constitution of the United States of America, Freedom of Information Act.
5: All public servants must take an oath to uphold the Constitution. See Article VI, Constitution of the united
states of America
6: I.R.S. Manual MT 9900-26– 1/29/75– Paragraph 241.5
7: Freedom of Information Act; Public Law 93-579, Sixth Amendment to the Constitution of the United States of America
8,9,10: Title 5 USC 552a, paragraph (d) (5), (e) (1), (e) (3) (A), (e) (3) (D)
12,13: Title 5 USC 552a paragraph (e) (3) (B), (e) (3) (C)
14: Public Law 93-579 (b) (1), Freedom of Information Act, Sixth Amendment to the Constitution of the united states of America
15: Title 5 USC 552a, paragraph (e) (3) (A)
16: Title 5 USC 552a paragraph (e) (2), Freedom of Information Act, Sixth Amendment to the Constitution of the United States of America.
17: Title 5 USC 552a. Paragraph (d) (5)
18,19: Public Law 93-579 (d) (1), Freedom of Information Act
20: Title 5 USC 552a paragraph (d) (1), Freedom of Information Act
21: Title 5 USC 552a paragraph (e) (10)