FD-484.pdf

FD-484

Revised

06-03-1982

FEDERAL BUREAU OF INVESTIGATION

PRIVACY ACT NOTICE FOR MAINTENANCE EMPLOYEES

PRIVACY ACT NOTICE

This is to advise you, in conformance with the Privacy Act of 1974, that the information solicited from you by personnel of the FBI is needed to complete background inquiries by the authority granted in Title 28, Part O, Subpart P, Paragraph 0.85, Subparagraph C, Code of Federal Regulations. The furnishing of this information is voluntary on your part and will be used to determine your eligibility for access to FBI space or certain FBI material. You should also be aware that willfully making a false statement or concealing a material fact could be a basis for refusing you access to FBI space or certain FBI material, and may constitute a violation of Section 1001, Title 18, United States

Code.

You are not required to execute this form; however, if you do not, this refusal may result in the inability of the FBI to obtain information necessary to complete background inquiries and thus lead to a denial of your request for access to FBI space or certain FBI material.

CONSENT

Signature of Applicant: Date:

FD-484 (Revised 06-03-1982) Page 1 of 1 FEDERAL BUREAU OF INVESTIGATION