PUBLIC SERVANT'S QUESTIONAIRE
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 and 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 in order that this individual may make a reasonable determination concerning divulgence of information to this agency.
1. Name of public servant______________________________
2. Residence __________ City __________ State __________ Zip__________
3. Name of department, bureau, or agency by which public servant
is employed__________ Supervisor's name __________
4. It's mailing address__________ City __________ State __________ Zip__________
5. Will public servant uphold the Constitution of the United States? __________
6. Did public servant furnish proof of identity? __________
7. What was the nature of proof?____________________
8. Will public servant furnish a copy of the law or regulation which
authorizes this investigation? __________
9. Will the public servant read aloud the portion of the law authorizing
the questions he will ask? __________
10. Are the answers to the questions voluntary or mandatory? __________
11. Are the questions to be asked based upon a specific law/regulation,
or are they being used as a discovery process? __________
12. What other uses may be made of this information? __________
13. What other agencies may have access to this information? __________
14. What will be the effect upon me if I should choose not to answer
any part or all of these questions? __________
15. Name of person in government requesting that this investigation be
16. Is this investigation 'general' or is it 'special'? __________
17. Have you consulted, questioned, interviewed, or received information
from any third party relative to this investigation? __________
18. If so, the identity of such third parties__________
19. Do you reasonably anticipate either a civil or criminal action to
be initiated or pursued based upon any of the requested information? __________
20. Is there a file of records, information, or correspondence relating
to me being maintained by this agency? __________ If yes, which? __________
21. Is this agency using any information pertaining to me which was
supplied by another agency or government source? __________
22. May I have a copy of that information? __________
23. Will the 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? __________ If not, why not? __________
If any request for information relating to me is received from any
person or agency, you must advise me in writing before releasing such
information. Failure to do so may subject you to possible civil or
criminal action as provided by the act.
I swear (affirm) that the answers I have given to the foregoing
questions are complete and correct in every particular.
X ____________________________ Date: ________/_________/_____________
Authorities for Questions:
1,2,3,4 In order to be sure you know exactly who you are giving the
information to. Residence and business addresses are needed in case you
need to serve process in a civil or criminal action upon this individual.
5 All public servants have taken a sworn oath to uphold and
defend the constitution.
6,7 This is standard procedure by government agents and officers.
See Internal Revenue Manual, MT-9900-26, Section 242.133.
8,9,10 Title 5 USC 552a, paragraph (e) (3) (A)
11 Title 5 USC 552a, paragraph (d) (5), (e) (1)
12,13 Title 5 USC 552a, paragraph (e) (3) (B), (e) (3) (C)
14 Title 5 USC 552a, paragraph (e) (3) (D)
15 Public Law 93-579 (b) (1)
16 Title 5 USC 552a, paragraph (e) (3) (A)
17,18 Title 5 USC 552a, paragraph (e) (2)
19 Title 5 USC 552a, paragraph (d) (5)
20,21 Public Law 93-579 (b) (1)
22 Title 5 USC 552a, paragraph (d) (1)
23 Title 5 USC 552a, paragraph (e) (10)
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