When the Department of Homeland Security issues this form to an individual, said individual will be allowed to divulge or expose any information about another person or entity.Download
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DHS Form 590 (8/11) Page 1 of 1 DEPARTMENT OF HOMELAND SECURITY AUTHORIZATION TO RELEASE INFORMATION TO ANOTHER PERSON Please complete this form to authorize the Department of Homeland Security (DHS) or its designated DHS Component element to disclose your personal information to another person. You are asked to provide your information only to facilitate the identification and processing of your request. Without your information DHS or its designated DHS Component element may be unable to process your request. SECTION I. Personal Information Name Telephone Number(s) Country Zip Code State City Address Name Address City State Zip Code Country Telephone Number(s) Date of Birth Place of Birth (city, state, country) SECTION II. Representative Information Pursuant to the Privacy Act of 1974 (5 U.S.C. §552a(b)), I authorize DHS and/or its DHS Component elements to release any and all information relating to my redress request to my representat\ ive . Pursuant to 28 U.S.C. §1746, 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 in Section I. I understand that falsification of this statement is punishable under the provisions of 18 U.S.C. §1001 by a fine of not more than $10,000 or by imprisonment of not more than five years, or both. Signature Date PR IV A CY A CT S TA TE M EN T: A UTH O RIT Y : T it le IV o f th e In te llig ence R efo rm a nd T erro ris m P re ve ntio n A ct o f 2 004 a uth oriz e s D HS to ta ke s e cu rit y m easu re s to p ro te ct tr a ve l, a nd u nder S ubtit le B , S ectio n 4 012(1 )(G ), th e A ct d ir e cts D HS to p ro vid e a ppeal a nd c o rre ctio n o pportu nit ie s fo r tr a ve le rs w hose in fo rm atio n m ay b e in co rre ct. P R IN CIP A L P U RPO SE(S ): D HS w ill u se th is in fo rm atio n in o rd er to a ssis t y o u w it h s e ekin g re dre ss in c o nnectio n w it h t r a ve l. R O UTIN E U SE(S ): D HS w ill u se a nd d is clo se th is in fo rm atio n to a ppro pria te g ove rn m enta l a gencie s to v e rif y y o ur id entit y , d is tin guis h y o ur id entit y fr o m th at o f a noth er in div id ual, s u ch a s s o m eone in clu ded o n a w atc h lis t, a nd/o r a ddre ss y o ur r e dre ss re quest. A ddit io nally , lim it e d in fo rm atio n m ay b e s h are d w it h n on-g ove rn m enta l e ntit ie s, s u ch a s a ir c a rrie rs , w here n ece ssa ry fo r th e s o le p urp ose o f c a rry in g o ut y o ur r e dre ss r e quest. D IS C LO SU RE: F urn is h in g th is in fo rm atio n is v o lu nta ry ; h ow eve r D HS m ay n ot b e a ble to p ro ce ss y o ur re dre ss re quest w it h out th e in fo rm atio n r e queste d.