________________________________  (name)              _______________________ 
________________________________  (address)                    (today's date) 
________________________________ 

Federal Bureau of Investigation 
Records Resources Division - Attn.: FOIA/PA Office 
J. Edgar Hoover Building 
9th & Pennsylvania Avenue NW 
Washington, DC  20535 

This is a request for records under both the Privacy Act and the Freedom 
of Information Act., because I would like to get a copy of the records 
about me at the FBI. 

I request a copy of any and all records at the FBI that mention me, such 
as documents, reports, memoranda, letters, electronic files, 'See Also' 
files, 'Do Not File' files, 'Official & Confidential' files, 'Personal & 
Confidential' files, photographs, audio tapes & videotapes, electronic or 
microphone surveillance (ELSUR or MISUR), or photographic surveillance, 
'June mail', 'Obscene' Files, 'Subversive' Indexes, bulkies, mail 
covers, trash covers; and any index citations relating to me or 
referencing me ('see also') in other files. Please search all your 
indexes, and interpret this request broadly.  This should include an 
ELSUR search.  I also request a copy of the 'FOIA Search Slip' generated 
as a result of this request. 

My full name is: ________________________________. My date of birth was 
_________________. 
My place of birth was: _______________________. Optional:  I have lived 
in places including: 
__________________________________________________________________________________Optional: 
Other names I've used; or places, events, publications, companies or 
organizations for which you may find applicable records: 
_______________________________________________________ 
__________________________________________________________________________________ 

FOIA/PA statutes provide that even if some of the requested material is 
properly exempt from mandatory disclosure, all segregable portions must 
be released. If the requested material is released with deletions, 
please mark each deletion to indicate the exemption(s) being claimed to 
authorize each particular withholding.  In addition, I ask that your 
agency exercise its discretion to release records which may be 
technically exempt, but where withholding serves no important public 
interest. 

I hereby agree to pay reasonable costs associated with this request up 
to a maximum of $30.  Please notify me if the fees are expected to 
exceed this amount.  I am aware that this request may take slightly 
longer than the time limit of 10 working days provided by law. 

NOTE:  I WANT ALL FILES, NOT JUST MAIN FILES.  DO IT RIGHT THE FIRST 
TIME OR I WILL SIMPLY APPEAL THE RESULT. 

NOTE:  My signature below has been certified by a  notary public as 
marked below. 

Sincerely, 

________________________________ 
      Requester's signature 

________________________________ 
     Requester's printed name 

________________________________________ 
 Notary stamp and signature (required)