MCIEAST-MCB CAMLEJ FREEDOM OF INFORMATION ACT

MCIEAST-MCB CAMLEJ

FREEDOM OF INFORMATION ACT/PRIVACY ACT REQUEST FORM

PRIVACY ACT STATEMENT

Information contained on this form is maintained under the Systems of Records Notice NM05720-1 FOIA Request/Appeal Files and Tracking System

(April 2, 2008, 73 FR 17961) 5 U.S.C. 552, the Freedom of Information Act, as amended. AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.

S.C. 5041, Headquarters, Marine Corps; E.O. 9397 (SSN); and Secretary of the Navy Instruction 5720.42F, Department of the Navy Freedom of

Information Act Program. PRINCIPLE: Individuals who request access to information under the provisions of the Freedom of Information Act (FOIA) or

make an appeal under the FOIA. PURPOSE: To track, process, and coordinate individual requests for access and amendment of personal records; to

process appeals on denials of requests for access or amendment to personal records; to compile information for reports, and to ensure timely response

to requesters. ROUTINE USE: In addition to those disclosures generally permitted under 5 U.S.C. 552a(b) of the Privacy Act, these records or

information contained therein may specifically be disclosed outside the DoD as pursuant to 5 U.S.C. 552a(b)(3). DISCLOSURE: MANDATORY for

computer matching.

MAILING ADDRESS: For more information please visit:

Commanding General

Attn: G-1 (FOIA Coordinator)

Marine Corps Installations East-Marine Corps Base Camp Lejeune

PSC Box 20005

Camp Lejeune, NC 28542-0005

You may return this request by faxing it back at (910) 451-1265 or

e-mail to [email protected]

Date REQUESTER completed this form:

I am willing to pay the fees above $15.00 for the processing of my request in the amount of: (if required)

Information requested:

(Describe information requested and where to locate the information)

Requester or Client's Name if other than requester):

Names of all persons involved: (if known)

Date of incident (DD MMM YY) : Location of Incident:

Requester Contact Information: (Print or type clearly)

Name:

Unit/Organization:

Rank:

Mailing Address: (Required for processing)

City: State: Zip Code:

Do you want to pick up the report or have it mailed to you?

PICK UP MAILED

E-MAIL

(Requester's Name (PRINT))

(Signature of Requester or agent)

(Signature required for processing)

PLEASE NOTE: This office has twenty (20) working days in which to provide a response to a FOIA Request.

Depending on current workloads, information requested, dates and/or accidents etc...the response time may vary.

MCIEAST-MCB CAMLEJ/G-1/ADJ/5720.1/1 (1/16) PREVIOUS EDITIONS ARE OBSOLETE ADOBE 9.0

REPORTING REQUIREMENT DD-5720-25 ARAD

(Phone Number)

SSN: (required for search)

"I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and

correct".

MCIEAST-MCB CAMLEJO 5720.1

Case Information: (Print or type clearly)

CLEOC (Electronic Report) All Documents

PMO Records Indicate:

Date Received:

MCIEAST-MCB CAMLEJ20

FREEDOM OF INFORMATION ACT (FOIA)

Attorney/Environmental/Investigation,

Military Police Incident Reports pertaining to

but not limited to: assault, breaking and

entering, drugs, domestic assault, burglary

and theft)

PRIVACY ACT (PA)

Personal information directly about

the individual, SRB, OPM, FAP

ROUTINE USE

OFFICIAL USE, Federal, State and local agency for

civil or criminal or for hiring, retention, Insurance

Company, accident report, security clearance and

contract

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