Date: [date]
To: [name of individual/company]
[address]
[city, state, zip]
Attention: [name if known]
Dear [Mr./Mrs. Smith, e.g.],
This request is made pursuant to the Federal Freedom of Information Act. I hereby request disclosure of any information about me that may be maintained in your files, to the extent disclosure is required by law.
Please direct response to:
Signed in the presence of:
_____________________________ _______________________________ Witness Signature [full name] __________________________________ Other names known by: __________________________________ __________________________________ [address] __________________________________ __________________________________ __________________________________ __________________________________ [social security number]