dhs-form-590, DHS TRIP Authorization to Release Information to Another Person

In the case of wanting to authorize releasing information to another person by the Department of Homeland Security, the following form has to be completed and submitted.

Extracted Text for Proper Search

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.