Privacy Act Request and Certification of Identity

Instructions

Per the Privacy Act of 1974, you may request a copy of records about you that are maintained in a Commission system of records. Your request may be made by providing the information and certification of identity that follow. Your request can be submitted electronically or printed and mailed to:

FOIA Compliance Office
Commodity Futures Trading Commission
Three Lafayette Centre
1155 21st Street, NW
Washington, DC 20581

PLEASE NOTE: To help ensure your privacy and security, unless you affirmatively extend your session when prompted, the online form will timeout after 65 minutes, and ALL DATA WILL BE LOST. You will then need to re-access the form to re-enter information in all the fields.

SECTION 1: REQUESTER CONTACT INFORMATION

4000 characters remaining.
4000 characters remaining.

To assist Commission personnel with locating records about you, we may contact you to request additional information.

SECTION 2: INFORMATION ABOUT THE RECORDS

* You can locate the applicable system of records notice here: https://www.cftc.gov/Privacy/SORN/index.htm

4000 characters remaining.
4000 characters remaining.
4000 characters remaining.

SECTION 3: CERTIFICATION OF IDENTITY

For the Commission to process your request, you must certify your identity. Please read the following statement and then sign and date where indicated below.


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. 552a(i)(3) by a fine of not more than $5,000.

SECTION 4: AUTHORIZATION TO RELEASE RECORDS TO ANOTHER PERSON

If you authorize the Commission to release records about you to another person (third party), please print that individual’s name, sign, and date below the following statement.


Pursuant to 5 U.S.C. Section 552a(b), I authorize the Commodity Futures Trading Commission to release any and all records about me to:

PRIVACY ACT

PRIVACY ACT STATEMENT

This notice is being provided pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a(e)(3), to inform you about why the Commodity Futures Trading Commission (“Commission”) is collecting this information.

  1. AUTHORITY


    The Commission is authorized to collect this information pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a and the Commission’s regulations at 17 CFR § 146.3.

  2. PURPOSE


    The information you provide on this form will be used by the Commission primarily to process your request for records subject to the Privacy Act.

  3. ROUTINE USES


    In addition, the Commission may disclose the information that you provide to a third party pursuant to a “routine use” where such a disclosure is required by law or otherwise deemed necessary and appropriate. A complete list of “routine uses” may be found in the relevant system of records notice, CFTC-40, Privacy Act Requests, 83 FR 3412, at https://www.federalregister.gov/d/2018-15392.

  4. EFFECT OF NOT PROVIDING THE INFORMATION


    Providing the information is voluntary; however, if you do not provide the information requested, the Commission may be unable to process your request.

FORM SUBMISSION