Consent for Disclosure of Records Protected under the Privacy Act Instructions: Please complete this form to provide consent and authorization for FERC to disclose your records to another person or entity. See here for more information on FERC’s Privacy Program. Information Used for Identity-Proofing and Authentication Title Title - None -MissMsMrMrsDrOther… Enter other… First Name Last Name By completing this form and in submitting information requested by ID.me, you are requesting information specific to the Federal Energy Regulatory Commission (FERC). By using the ID.me service, you are voluntarily providing Personally Identifiable Information (PII) to a non-government third party, not owned or controlled by FERC. Please see FERC’s complete Privacy Notice regarding ID.me here. Verify with ID.me Additional Information Required to Locate the Record(s) Please describe what information is requested. Please provide enough detail so that knowledgeable staff may locate the record(s) with a reasonable amount of effort. The description should include the time frame to be searched, as well as titles of document and offices to be searched. The more detail you provide, the better opportunity there is to determine if the records exist and where. Name of Recipient (Person or Entity) to Whom Disclosure is Authorized Title Title - Select -MissMsMrMrsDrOther… Enter other… First Name Last Name Address for Receiving Records Country - None -AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSamoaSan MarinoSão Tomé & PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabwe Certification for Consent to Disclose Records 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 and consenting to and authorizing disclosure of my records, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of not more than five years, or both, and that requesting or obtaining any record(s) under false pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000. Electronic Signature acknowledging the above Placing your name inside this field represents your legal signature and consent. Privacy Act Statement In accordance with FERC’s Privacy Act policies, personal information sufficient to identify the individuals requesting access to records under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of this solicitation is to ensure that the records of individuals who are the subject of FERC’s systems of records are not wrongfully disclosed by FERC. Requests will not be processed if this information is not furnished. False information on this form may subject the requester to criminal penalties under 18 U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3). Please see FERC’s SORNs at https://www.ferc.gov/privacy/ferc-system-records-notice-sorn, specifically, relating to Privacy Act requests here, https://www.govinfo.gov/content/pkg/FR-2016-09-07/pdf/2016-21418.pdf, and here https://www.govinfo.gov/content/pkg/FR-2014-03-28/pdf/2014-06993.pdf. Submit Leave this field blank
