Scribd Logo
Upload

Welcome to Scribd!

  • 368 views

    Certification of Identity: Federal Deposit Insurance Corporation

    Uploaded by

    OneNation
    This document is a privacy act statement and certification of identity form from the Federal Deposit Insurance Corporation (FDIC). The form requires requesters to provide personal identifying information, including their name, address, date of birth, and place of birth, in order to access records. It also allows requesters to authorize the release of their information to another person. The form warns that falsifying information is a criminal offense and requesting records under false pretenses is punishable under law.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Certification of Identity: Federal Deposit Insurance Corporation

    Uploaded by

    OneNation
    368 views2 pages
    This document is a privacy act statement and certification of identity form from the Federal Deposit Insurance Corporation (FDIC). The form requires requesters to provide personal identifying information, including their name, address, date of birth, and place of birth, in order to access records. It also allows requesters to authorize the release of their information to another person. The form warns that falsifying information is a criminal offense and requesting records under false pretenses is punishable under law.

    Original Title

    f1360-09

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a privacy act statement and certification of identity form from the Federal Deposit Insurance Corporation (FDIC). The form requires requesters to provide personal identifying information, including their name, address, date of birth, and place of birth, in order to access records. It also allows requesters to authorize the release of their information to another person. The form warns that falsifying information is a criminal offense and requesting records under false pretenses is punishable under law.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    368 views2 pages

    Certification of Identity: Federal Deposit Insurance Corporation

    Uploaded by

    OneNation
    This document is a privacy act statement and certification of identity form from the Federal Deposit Insurance Corporation (FDIC). The form requires requesters to provide personal identifying information, including their name, address, date of birth, and place of birth, in order to access records. It also allows requesters to authorize the release of their information to another person. The form warns that falsifying information is a criminal offense and requesting records under false pretenses is punishable under law.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Federal Deposit Insurance Corporation

    CERTIFICATION OF IDENTITY

    PRIVACY ACT STATEMENT

    In accordance with 12 C.F.R. Part 310.4, personal information sufficient to identify the individuals requesting access to
    records under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of this solicitation is to ensure that the
    records of individuals who are the subject of Federal Deposit Insurance Corporation (FDIC) systems of records are not
    wrongfully disclosed by the FDIC. The information you provide may be shared with appropriate Federal, state, local, or
    foreign law enforcement authorities; a court, administrative tribunal, or party in litigation; and contractors, agents, and
    other third parties as authorized by law and in accordance with any of the other routine uses described in the FDIC
    Freedom of Information Act and Privacy Act Request Records (FDIC-022) System of Records available at www.fdic.gov/
    about/privacy. Requests will not be processed if this information is not furnished. False information on this form may
    subject the requester to criminal penalties under 18 U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3). If you have questions or
    concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at
    Privacy@fdic.gov.

    Page down to access form 1360/09

    FDIC 1360/09 (3-23) Page 1 of 2


    Federal Deposit Insurance Corporation
    CERTIFICATION OF IDENTITY
    SECTION I - REQUESTER INFORMATION
    1. Full Name of Requester1 (Last, First, MI)

    2. Current Address (Street, City, State, ZIP Code)

    3. Date of Birth 4. Place of Birth

    SECTION II - AUTHORIZATION TO RELEASE INFORMATION TO ANOTHER PERSON (OPTIONAL)


    This form is also to be completed by a requester who is authorizing information relating to himself or herself to be
    released to another person. Further, pursuant to 5 U.S.C. Section 552a(b), I authorize the Federal Deposit Insurance
    Corporation to release any and all information relating to me to:

    5. Print or Type Name (If Applicable)

    SECTION III - DECLARATION

    I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct,
    and that I am the person named above, and I understand that any falsification of this statement is punishable under the
    provisions of 18 U.S.C. Section 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years
    or both, and that requesting or obtaining any record(s) under false pretenses is punishable under the provisions of 5
    U.S.C. Section 552a(i)(3) by a fine of not more than $5,000.

    6. Requester Signature2 7. Date

    1
    Name of individual who is the subject of the record(s) sought.
    2
    Signature of individual who is the subject of the record sought.

    FDIC 1360/09 (3-23) Page 2 of 2

    You might also like