March 11, 2025
U.S. Department of Government Efficiency
736 Jackson Place, NW
Washington, D.C. 20503
United States Digital Service
736 Jackson Place, NW
Washington, D.C. 20503
RE: Privacy Act Access Request
Dear Privacy Officer or Coordinator:
In accordance with the Privacy Act, 5 U.S.C. § 552a(d)(1), I request copies of (1) all
records about or pertaining to me in the possession or control of the U.S. Department of
Government Efficiency (DOGE) or the United States Digital Service (USDS), and (2) all records
about or pertaining to me contained within any system of records in the possession or control of
DOGE and USDS, including any records or information about or pertaining to me that is
contained in a copy, made or received by an employee or contractor of DOGE or USDS,
including members of “DOGE Teams” or other DOGE-affiliated individuals.
Additionally, pursuant to 5 U.S.C. § 553a(c)(3), I request that you provide an accounting
of the date, nature, and purpose of any disclosures that you, your agency, or your organization
have made under 5 U.S.C. § 552a(b) providing access to a record about me to another person,
organization, or agency, including within the Executive Office of the President.
I further request that you confirm that DOGE, USDS, and members of “DOGE Teams”
or other DOGE-affiliated individuals will comply with the requirement of 5 U.S.C. § 553a(e)(7),
that no agency may maintain records cross-referenced with information about how I have
exercised rights guaranteed by the First Amendment unless expressly authorized by statute or
unless pertinent to an authorized law enforcement activity.
To facilitate your response, I provide below my contact information and an itemized list
of the records sought:
Privacy Act Access Request
Page 2
Full name: _________________________________________
Mailing address: _________________________________________
_________________________________________
Preferred email address: ___________________________________
Date and place of birth: _________________________________________
Requested records pertaining to me containing my name, or the identifying number,
symbol, or other identifying particular assigned to me:
◦ Education records
◦ Financial transaction records
◦ Medical histories
◦ Records relating to my eligibility for government benefits
◦ Criminal or employment histories
◦ Dissemination of my data to other entities: Pursuant to 5 U.S.C. § 552a(o)(2)(A)(ii),
if any such records have been transmitted to a recipient agency as defined in 5 U.S.C. §
522a(a)(9), provide me a with copy of the written agreement between DOGE and/or USDS and
the recipient agency or non-Federal agency specifying — (A) the purpose and legal authority for
conducting the program; (B) the justification for the program and the anticipated results,
including a specific estimate of any savings; (C) a description of the records that will be
matched, including each data element that will be used, the approximate number of records that
will be matched, and the projected starting and completion dates of the matching program; D) all
other information required in such written agreement under 5 U.S.C. § 552a(o)(1)(A)-(K).
Privacy Act Access Request
Page 3
Where possible, please provide responsive materials in an electronic format by mail to :
________________________________________________[INSERT email address].
Alternatively, please provide responsive materials in native format or in PDF format on a
USB drive. Please send any responsive material sent in paper or USB drive form by mail to:
_______________________________________ [INSERT preferred mailing address].
If you contend that inspection of records must occur in person, provide me with
accessible place(s) of inspection and the procedure to schedule it. Under 5 U.S.C. §552a(f)(5),
you may not charge any fees for the search and review of these records. If paper copies are
provided, please state the cost of duplication, and whether it exceeds the standard $0.05 per page.
If you deny this request, in whole or in part, please cite each specific exemption you feel
justifies the refusal to release the information and notify me of appeal procedures available to me
under the law. I expect a timely acknowledgement, response, and production of the requested
records and information in accordance with the requirements of the Privacy Act.
Sincerely,
______________________________________________________
[WET SIGNATURE]
IDENTITY VERIFICATION
In accordance with 28 U.S.C. § 1746, I, ____________________________[INSERT FULL
NAME], 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
records about me. I understand that any falsification of this statement is punishable under the
provisions of 18 U.S.C. § 1001 by a fine of not more than $5,000, imprisonment for not more
than eight years, or both, and that knowingly and willfully requesting or obtaining any record
about any individual from an agency 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.
Dated: ________________ ____________________________________
[WET SIGNATURE]
