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 Issues
CA/OCS/CI, Room L127
2401 E Street, N.W. (SA-1)
U.S. Department of State
Washington, D.C. 20037

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIVACY ACT WAIVER FORM
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