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email PRIVACY ACT WAIVER FORM
PRIVACY ACT WAIVER FORM
(explanation)
In accordance with the Privacy Act (PL 93-579) passed by Congress in 1974, U.S. Department of State personnel are not permitted to release any information not deemed to be in the public domain, regarding private individuals, without the express written consent of the concerned citizen(s).
It is therefore requested that you complete the attached authorization, specifying those persons and/or organizations the Office of Children’s Issues (CA/OCS/CI) may contact, and to whom the Office of Children’s Issues may release information regarding your case. Please return this form to the Consular Officer who is handling your case at:
Office of Children’s IssuesCA/OCS/CI, Room L127
2401 E Street, N.W. (SA-1)
U.S. Department of State
Washington, D.C. 20037
FOR USE BY THE OFFICE OF CHILDREN’S ISSUES,
BUREAU OF CONSULAR AFFAIRS, U.S. DEPARTMENT OF STATE
A. Child’s name:_____________________________________________________________ Country where the child has been taken or is being retained:_____________________ Your name and your relationship to the child:__________________________________B. Names, addresses and telephone numbers of persons and/or organizations you want us to contact proactively with information regarding the child’s case:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________C. Please circle "Yes" or "No" as appropriate: In the event that persons or organizations other than those specified above request information regarding your case, the Office of Children’s Issues may release information to: Family members other than those listed above. YES NO Friends other than those listed above. YES NO Individual Members of Congress. YES NO Members of the Press. YES NO The General Public. YES NO Information will only be released under Section C if requested, and if we have your express authorization.__________________________________________Printed or Typed Name of Authorizing Party________________________________________ _____________________________Signature Place and Date Signed
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