Consent for Disclosure of Records Protected under the Privacy Act

If you are providing consent and authorizing the SEC to disclose your records to another person or entity, you must provide the following information and sign the statement below.

In order for your records to be disclosed to a third party, you must provide a signature below, which acknowledges that you have read and understand the following statement:

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 requesting access to my records or to information pertaining to me, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, 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.

Privacy Act Statement

In accordance with the SEC’s Privacy Act Regulation, 17 C.F.R. Subpart H, personal information sufficient to identify the individuals requesting access to records under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of this solicitation is to ensure that the records of individuals who are the subject of SEC systems of records are not wrongfully disclosed by the SEC. Additionally, the SEC may use the information, as necessary and authorized by the routine uses published in the SEC System of Records Notice Freedom of Information and Privacy Act Requests, 78 FR 41962 (July 12, 2013). Requests will not be processed if this information is not furnished. False information on this form may subject the requester to criminal penalties under 18 U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3).