Sample Privacy Act Request for Access Letter

Privacy Act Officer [or System of Records Manager] 
Name of Agency 
Address of Agency 
City, State, Zip Code 

Re: Privacy Act Request for Access 

Dear : 

This is a request under the Privacy Act of 1974. 

I request a copy of any records [or specifically named records] about me maintained at your agency. 

[Optional] To help you to locate my records, I have had the following contacts with your agency: [mention job applications, periods of employment, loans or agency programs applied for, etc.]. 

[Optional] Please consider that this request is also made under the Freedom of Information Act. Please provide any additional information that may be available under the FOIA. 

[Optional] I am willing to pay fees for this request up to a maximum of $_____. If you estimate that the fees will exceed this limit, please inform me first. 

[Optional] Enclosed is [a notarized signature or other identifying document] that will verify my identity. 

Thank you for your consideration of this request. 

Sincerely, 

Name 
Address 
City, State, Zip Code 
Telephone number [Optional]