Protected when completed
For official use only
Personal Information Request Form
- Federal Government Institution:
- I wish to examine the information
- As it is
- All in English
- All in French
- Provide details regarding the information being sought (e.g. subject matter, date range, type of records):
- Method of access preferred (Please choose one)
- Receive paper copies of the documents
- Receive electronic copies of the documents
- Examine the documents in government offices
- Name of applicant:
- Street, address, apartment:
- City or town:
- Postal Code:
- Telephone number:
- I am a Canadian citizen, permanent resident, or an individual present in Canada, and request personal information about myself.
- I request personal information on behalf of another individual who is a Canadian citizen, permanent resident or an individual present in Canada.
Please note that the institution may contact you to verify your identity and to confirm that you have a right of access under the Privacy Act.
The personal information provided on this form is protected under the provisions of the Access to Information Act and the Privacy Act and is retained and used as described in Personal Information Bank PSU 901 of the institution to which this form is submitted.
Determine which federal government institution is most likely to hold personal information about you using the publication Info Source: Sources of Government and Employee Information (http://infosource.gc.ca/emp/emp05-eng.asp#chapters). Decide if you wish to submit an informal request for the information or a formal request under the Privacy Act. If you wish to make an informal request, contact the institution’s Access to Information and Privacy Coordinator (http://www.tbs-sct.gc.cahttp://www.tbs-sct.gc.ca/ap/atip-aiprp/coord-eng.asp).
To obtain your personal information under the Privacy Act, complete this form. Describe the information being sought and provide relevant details necessary to help the institution find it. If you require assistance, refer to Info Source (http://infosource.gc.ca/)for a description of records held by the institution or contact the institution’s Access to Information and Privacy Coordinator.
Forward this form to the Access to Information and Privacy Coordinator of the institution holding the information.
Should you have any questions about the response to your request, please contact the Access to Information and Privacy Office of the institution. You have the right to complain to the Privacy Commissioner of Canada if you believe that you have been denied any of your rights under the Act.
TBC/CTC 350-0058E (Rev. 06/2014)
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