Instructions: Use of this form is optional. You may use any written format for a Freedom of Information (FOIA) or Privacy Act (PA) Request as long as it contains: 1) a description of the information you are requesting; and 2) sufficient personally identifying data, when required. Without this required information, USAID cannot process your request. Completed forms should be submitted by fax, mail, or e-mailed as scanned attachments. If submitting via e-mail, you should ensure that the security of your e-mail system is adequate for transmitting sensitive information before choosing to transmit your request which contains your personally identifiable information. If submitting via e-mail, for security reasons encrypt the message with the completed form, and use the same email address to send a password in a separate email message. Mail: U.S. Agency for International Development, M/MS/IRD, Suite 2.07C RRB, 1300 Pennsylvania Avenue NW, Washington, DC 20523-2701. Fax: 202-216-3070. E-Mail:

Expiration: 06/2025