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FBI Privacy Waiver Form for Individual Named Dale (DOB 1/20/1953) – Minimal Detail

The document is a standard privacy waiver and identity certification with no substantive allegations, transactions, or connections to high‑level officials. It merely records personal data and a reques Form filed on 16‑Apr‑2010 by the FBI in Winchester, VA. Subject: Dale, born 1/20/1953, former resident of Kings County, NY; address listed in Palm Beach, FL Contains standard legal language about pen

Date
November 11, 2025
Source
House Oversight
Reference
House Oversight #021676
Pages
1
Persons
0
Integrity
No Hash Available

Summary

The document is a standard privacy waiver and identity certification with no substantive allegations, transactions, or connections to high‑level officials. It merely records personal data and a reques Form filed on 16‑Apr‑2010 by the FBI in Winchester, VA. Subject: Dale, born 1/20/1953, former resident of Kings County, NY; address listed in Palm Beach, FL Contains standard legal language about pen

Tags

legal-documentidentity-verificationidentity-certificationfbiprivacy-waiverhouse-oversightfoia
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Browse House Oversight Committee ReleasesHouse Oversight #021676

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Extracted Text (OCR)

EFTA Disclosure
Text extracted via OCR from the original document. May contain errors from the scanning process.
_. APR-16-2010 13:43 FBI ICRC WINCHESTER VA P.004 Federal Bureau of InvestigatioMfrivacy Waiver and Certification of Identit Page 1 of 1 Cemplote. vlan, and.mall (orginal signature needed) 0S. Departmont of Justice Federal Bureau of Investigation i Privacy Walver and Certification of identity pultenc Jeitzey E- Bpstetn Attpan axed: ; corm adieen 358 EL Brille Wav, Palm Beach, FL 33480 00 Dale or Births 1/20/1953 Placo of mnu_Kings County, New York Soda socuily Numborfoptonun OFO—44-3348 | Options: Prlor sddreasas, ciphers 614, which may assiat Uia FB In (ocating tho naquested invormadion} Thereby walve my dghtao privacy, and | authorize tha PUI to release any and all Information rateting to me to: 4 (Rame, edidorse.& phone of attorney Of citer deslanes} ' 53 P Plaza), Shite a Boston MA O2Z116 -—- 617 227 3700 Undor penalty of 1 Chord am tho on: shove and undorsinnd thateny faificotion ef thle slatemont ts punishable undar tho Provisiono 418, Untiod Stoths Code (V5.0), Sucve (001 by 6 fite.of not mote then $10,000 of by Imartzonmenl of not mong then tive years, of both: and thal raquastig zon te punishable under the provisions of Tits 6. U.6.C., Section 5526 (0(3) ov a oisdamannor ond by & fino of Dots; l 5/ g {oo | ' littp://foia.foi.gov/waiver-him 12/29/2009 t. I TOTAL P.004 . i ’ t

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Domainfoia.foi.gov
Phone617 227 3700

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