REQUEST UNDER FREEDOM OF INFORMATION ACT

Date: ___________________________

To: ________________________________





Dear ______________________:


Pursuant to the Federal Freedom of Information Act, I request disclosure of such information on me as may be maintained in your files, and to the extent said disclosure is required by law.

Please forward said information to the address below.

I appreciate your cooperation.




In the presence of:


______________________________         _______________________________
Witness                                                         Signature

_______________________________
Name (Printed or Typed)

_______________________________
Other Known Names

_______________________________
Address

_______________________________

_______________________________

_______________________________
Social Security No.