Click on the pdf below.



If one clicks on the following pdf file, one may access the questionnaire that details one’s Federal Rights to Privacy which originate from US Code,  5.5 USC 552a (e)(3).  This Federal statute authorizes a sovereign natural person (“Citizen”) to use this form to collect information from the Public Servant to determine whether to divulge information to the Public Servant and employing Agency. Public Law 93-579 states: “The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy requiring Federal agencies… to permit an individual to determine what records pertaining to him are collected, maintained, used or disseminated by such agencies…” :


PUBLIC SERVANT’S QUESTIONNAIRE (Refer to Privacy Act of 1974)
Public Servant Full Name ID Refused?
Driver License #                              Refused?                                 Badge #


Residence Address Street City State Zip
Office Mail Address Street City State Zip
Employing Agency or Department  Supervisor’s Name
1. Will Public Servant uphold the Constitution of the United States of America (required by USA & State Constitution & Law)?      Yes      No


2. Will Public Servant furnish a copy of the law or regulation which authorizes this investigation (5 USC 552a (e) (3) (A))?              Yes      No
3. Will Public Servant read aloud that portion of the law authorizing the questions Public Servant will ask (5 USC 552a (e) (3) (A))?        Yes      No

4. What prerogative does Citizen have in giving answers to Public Servant questions (5 USC 552a (e) (3) (A))?

        Voluntary             Mandatory
5. What basis exists for asking the intended questions (5 USC 552a (d)
(5), (e) (1))?

Specific law or regulation:


Used as a discovery process:


6. What nature does this investigation have (5 USC 552a (e) (3) (A))?

 General (multiple people involved)                         Special (one person involved)
7. Does Public Servant reasonably anticipate that any information sought or collected in this investigation will form the basis of or lead to criminal action against Citizen or any other entity?                                      Yes                       No

8. Will Public Servant guarantee only the department employing Public Servant will use the information or derivative thereof supplied by Citizen in this investigation (5 USC 552a (e) (10))?  

         Yes                           No
9. Name all files of records, information, or correspondence related to Citizen that Agency maintains (PL 93-579 (b) (1))?



10. Give the full name of the person in government requesting that Public Servant conduct this investigation (PL 93-579 (b) (1))


No One
11. Name and identify all third parties Public Servant consulted, questioned, interviewed, or received information from any third party relative to this investigation (5 USC 552a (e) (2), (d) (5)).

12. Name all other agencies or government sources that supplied any information pertaining to Citizen (PL 93-579 (b) (1))?


13. May Citizen have a copy of all information pertaining to Citizen that other agencies or government sources supplied (5 USC 552a (d) (1))? Yes No (If no, state authority for withholding info)

No Authority
14. What other uses may be made of this information (5 USC 552a (e) (3) (B), (e) (3) (C))?

15. What other agencies may have access to this information (5 USC 552a (e) (3) (B), (e) (3) (C))?

16. What will be the effect upon Citizen if Citizen should choose not to answer any part of these
questions (5 USC 552a (e) (3) (D))?


Public Servant Affirmation:

I swear or affirm under penalty of perjury that I have answered the foregoing questions correctly and completely in every particular.


Wet ink signature of Public Servant                                                                 Date:

Administered Oath Date Witness Name:                                                        Date:


Note: Citizen may administer oath to Public Servant if no one else exists to witness Public Servant affirmation.


Disclaimer:  The author of this blog is not and does not purport or misrepresent to be, and is certainly no substitute for a licensed, board-certified specialist  attorney, lawyer, legal practitioner, or trial advocate, and, therefore, Author of this blog is not  qualified to give any legal advice to anyone whose case is not her own.  Everything on this blog is intended to be and should be construed to be for educational purposes, personal knowledge, and/or entertainment purposes.  This post is made in good faith, and is intended for other individuals who are acting lawfully and in good faith.  If one were to ever use this “Public Servant Questionnaire,” or rather, test it as an experiment, one would do so at one’s own risk.


Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s