Public Servant Questionnaire, Adapted by Bob Hurt

THE PUBLIC SERVANT QUESTIONNAIRE
Key Points:
An American does not have to speak with a government agent unless the citizen
has been arrested.
Americans have a right to privacy, to be left alone.
The PRIVACY ACT OF 1974 (Public Law 93-579), empowers citizens to require
full, written disclosure from a government official who seeks information.
You may insist on complete disclosure as a precondition to speaking with any

government official.
The Limits On Federal Power:
Law-abiding citizens are sometimes visited by agents of the Federal government

for no apparent reason. It is helpful, at the time of these visits, to recall that unless a
citizen has been placed under arrest (either because a law enforcement officer has
probable cause to believe the citizen has committed a crime or because the officer
has in his possession an arrest warrant issued by a judge who believes there is
probable cause the citizen has committed a crime, a citizen does not have to
entertain the company of government agents.
Citizens also have the right, guaranteed by the Fifth Amendment to the United
States Constitution, not to testify against themselves. Thus, when "the government"
comes knocking on one¹s door, you have the right to simply say, "Please go away."
Unless the government officer places you under arrest (there must be probable cause,
or an arrest warrant based on probable cause), the officer must obey your wishes.
Be Helpful.... On Your Terms
Of course, citizens also have a vested interest in assisting "the

government" in its role of crime-solver. Most of us understand the need to help "the
government" to apprehend criminals. But it is also helpful, when "the government"
arrives at your place of employment or at your home, to know how to find out why
government agents have appeared on YOUR doorstep.
A handy little questionnaire that I came across years ago will do the trick. It¹s
called the "Public Servant Questionnaire." A version
accompanies this article. The "PSQ" was developed by Lynn Johnston, author of
Who's Afraid of the IRS? (Libertarian Review Foundation: 1983, ISBN 0-930073-03-7).
The PSQ is based on the requirements placed upon the government by the
Privacy Act of 1974 (Public Law 93-579), an amending law to Title 5, United States
Code, Section 552, and is included as Section 552a.
If a citizen chooses to cooperate with government officials who are seeking

information, BEFORE questioning begins, the citizen should politely inform the
government agent or agents that a prerequisite for the citizen's cooperation with "the
government" is the agent¹s cooperation with the citizen.
Do It Right, The First Time
The questions should then be put to each agent, and the citizen should enter the
answers onto the questionnaire. Copies should be provided to each agent, either at
the time of the questioning or by mail to the agent after the visit. The questionnaire
informs the government agent that the citizen knows his rights and knows which
limited powers the government agent has been granted by the people.
Most probably some government agents will not want to fill out or sign the PSQ.
That’s fine. They can then be sent on their merry way. They may need to explain to
their superiors, and a court of law, and a jury, on another day, why they refused to
cooperate with the reasonable questions of the highest officeholder in the land, a
citizen.
5 USC 552a (e)(3) 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 ID #
Full Name Refused?
Driver License # Badge #
Refused? Refused?
Residence
Address Street City State Zip
Office Mail
Address Street City State Zip
Employing Supervisor’s
Agency or Dept Name
1. Will Public Servant uphold the Constitution of the United States of 2. Will Public Servant furnish a copy of the law or regulation which
America (required by USA & State Constitution & Law)? Yes No authorizes this investigation (5 USC 552a (e) (3) (A))? Yes No
3. Will Public Servant read aloud that portion of the law authorizing the 4. What prerogative does Citizen have in giving answers to Public Servant
questions Public Servant will ask (5 USC 552a (e) (3) (A))? Yes No questions (5 USC 552a (e) (3) (A))? Voluntary Mandatory
5. What basis exists for asking the intended questions (5 USC 552a (d) 6. What nature does this investigation have (5 USC 552a (e) (3) (A))?
(5), (e) (1))? Specific law or regulation Used as a discovery process General (multiple people involved) Special (one person involved)
7. Does Public Servant reasonably anticipate that any information sought 8. Will Public Servant guarantee only the department employing Public
or collected in this investigation will form the basis of or lead to criminal Servant will use the information or derivative thereof supplied by Citizen in
action against Citizen or any other entity? Yes No 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))? Î None
10. Give the full name of the person in government requesting that
Public Servant conduct this investigation (PL 93-579 (b) (1)) Î 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)). Î None
12. Name all other agencies or government sources that supplied
any information pertaining to Citizen (PL 93-579 (b) (1))? Î None
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) Î No Authority
14. What other uses may be made of this information
(5 USC 552a (e) (3) (B), (e) (3) (C))? Î None
15. What other agencies may have access to this
information (5 USC 552a (e) (3) (B), (e) (3) (C))? Î None
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))? Î None
Public Servant Affirmation: I swear or affirm under penalty
of perjury that I have answered the foregoing questions
correctly and completely in every particular. Î Wet ink signature of Public Servant Date
Citizen’s Witnessing Name and Signature Administered Oath Date Witness Name and Signature Date
Note: Citizen may administer oath to Public Servant if no one else exists to witness Public Servant affirmation.

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THE PUBLIC SERVANT QUESTIONNAIRE

Americans have a right to privacy, to be left alone.

You may insist on complete disclosure as a precondition to speaking with any

The Limits On Federal Power:

Law-abiding citizens are sometimes visited by agents of the Federal government

Be Helpful.... On Your Terms

Of course, citizens also have a vested interest in assisting "the

If a citizen chooses to cooperate with government officials who are seeking

Do It Right, The First Time

PUBLIC SERVANT'S QUESTIONNAIRE (Refer to Privacy Act of 1974)

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