_. APR-16-2010 13:43 FBI ICRC WINCHESTER VA P.004 Federal Bureau of InvestigatioMfrivacy Waiver and Certification of Identit Page 1 of 1
Cemplote. vlan, and.mall (orginal signature needed)
0S. Departmont of Justice
Federal Bureau of Investigation
i Privacy Walver and Certification of identity
pultenc Jeitzey E- Bpstetn Attpan axed: ;
corm adieen 358 EL Brille Wav, Palm Beach, FL 33480 00 Dale or Births 1/20/1953 Placo of mnu_Kings County, New York Soda socuily Numborfoptonun OFO—44-3348 |
Options: Prlor sddreasas, ciphers 614, which may assiat Uia FB In (ocating tho naquested invormadion}
Thereby walve my dghtao privacy, and | authorize tha PUI to release any and all Information rateting to me to: 4
(Rame, edidorse.& phone of attorney Of citer deslanes} '
53 P Plaza), Shite a Boston MA O2Z116 -—- 617 227 3700
Undor penalty of 1 Chord am tho on: shove and undorsinnd thateny faificotion ef thle slatemont ts punishable undar tho Provisiono 418, Untiod Stoths Code (V5.0), Sucve (001 by 6 fite.of not mote then $10,000 of by Imartzonmenl of not mong then tive years, of both: and thal raquastig zon te punishable under the provisions of Tits 6. U.6.C., Section 5526 (0(3) ov a oisdamannor ond by & fino of
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littp://foia.foi.gov/waiver-him 12/29/2009
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TOTAL P.004
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HOUSE_OVERSIGHT_021676