Public Servant Questionnaire
This
questionnaire must be filled-out by any public servant before he can ask the
citizen any question. This is authorized
by federal law, including the Privacy Act, 5 U.S.C. 552a, 88 Stat. 1896, et
seq., 1974.
1. Public servant's full legal name:
2. Public servant's residence address:
3.
Name of agency:
4.
Name of supervisor and office address:
5.
Will public servant uphold the constitution of the United States?
Yes No
6.
Did public servant provide proof of identity?
Yes No
7.
ID number:
Badge Number:
Bonding agency and number:
8.
Will public servant furnish a copy of the law or regulation that
authorizes the action being taken or information requested in this case?
Yes No
9.
Will public servant read aloud that portion of the law authorizing the
questions asked?
Yes No
10.
Are answers voluntary or mandatory?
Voluntary Mandatory
11.
Are the questions being asked based upon a specific law or regulation,
or are they a discovery process?
12.
What other uses may be made of this information?
13.
What other agencies may have access to this information?
14.
What will be the effect upon me if I should not choose to answer any or
all of these questions?
15.
Name of person in government requesting this information:
16.
Is this investigation general or special?
Note: by ‘general,’ it means
any kind of blanket investigations
in which a number of persons are involved because of geography, type of
business income, etc. By
‘special,’ it means any investigation of an individual nature in which others
are not involved.
17.
Have you consulted, questioned, interviewed, or received information
from any third party relating to this matter?
Yes No
18.
If yes, give identity of all such third parties:
19.
Do you reasonably anticipate either a civil or criminal action to be
initiated or pursued based upon any of the information which you seek?
Yes No
20.
Is there a file of records, information, or correspondence relating to
me being maintained by this agency?
Yes No
21.
Is this agency using any information on me which was supplied by another
agency or government source?
Yes No
22.
Will the public servant guarantee that the information in these files
will not be used by any other department other than the one by which he is
employed?
Yes No
I hereby sign and affirm under the
penalty of perjury that the answers are true and correct in every particular.
_____________________________________
Signature of public servant
Notice: If any
request for information relating to me is received by any person or agency, you
must advise me in writing before releasing such information. Failure to do so may subject you to possible
civil or criminal action as provided by this act or other law(s).
Official printable questionnaire:
http://www.landandwaterusa.com/Property-Protection-Forms/Public-Servants-Questionnaire.pdf
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