Date
 
Commander, U.S. Fleet Forces Command
ATTN:  Privacy Coordinator
1562 Mitscher Ave, Suite 250
Norfolk, VA  23551-2487
 
Dear Privacy Act Coordinator:
 
I request the following information pertaining to me:
 
(Provide a detailed description of the documents/records you want, and a description of the nature, time, place and circumstances of your association with U.S. Fleet Forces Command, in order for a search for responsive records to be conducted.)
 
Under penalty of perjury, I hereby declare that I am the person named below and I understand that any falsification of this statement is punishable under the provisions of Title 18, United States Code (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 Title 5, U.S.C., Section 552a(i)(3) as a misdemeanor and by a fine of not more than $5,000.”
 
My contact information is as follows:  (Mailing address is required; telephone and email information is optional, but failing to provide it may potentially delay the final response.)
 
 
 
FULL NAME/SIGNATURE (Required)