Your Name Today's Date
Your Address
Line 2 of Your Address

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.

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: Your Name. My date of birth is: Your Date of Birth. My place
of birth is: Your Place of Birth. Optional: My social security number is: Your
SSN.

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.

Sincerely,
Your Signature

Your Printed Name

Notary Stamp and Signature

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If life gives you melons, you may be dyslexic.