Bureaucracy Encounter Form
Dear Bureaucrat:
You have requested certain information or action of me.  As you are a Public Servant,
and in order for me to better facilitate your request, I require certain information for mine
own records (under Title 5, USC).
When you have filled out this form in triplicate, I will then consider your request.
Fill out completely a separate form in triplicate for each request of me you have made
or choose to make. If additional room is needed, use another sheet of paper.
Refusal to fill out this form and/or refusal to sign this form acknowledges and
acquieses on your part no authority or jurisdiction with which to proceed.

Today's date: ___/___/___  Location: _________________________________________________
Your name:  ______________________________________________________________
Agency(ies) you represent: _________________________________________________________
Your business address:  c/o ________________________________________________________
City:  _____________________________________________________________________
state (two letter State initials not accepted): _____________________________________
Postal code: [ ___________-9999 ]  Telephone number: _________________________________
Your badge/identification number: _____________________________
Your Social Security number: ________________________________
Your date of birth: __________________________________________
Your annual salary: _________________________________________

Your supervisor's name: _____________________________________
Supervisor's telephone number: _______________________________

Describe your request in detail: _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________

Are you required to make this request?		YES / NO  (Circle one)
If so, what person or agency required it of you? ________________________________________

Are you authorized to make this request?	YES / NO  (Circle one)
If so, what person or agency authorized you? __________________________________________

State what statute, and what section and/or subsection(s) of that statute authorizes you to make this request: ______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

State which portion of the state and/or national constitution authorizes you to make this request:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Have you filled out a form like this for me in the past?	YES / NO  (Circle one)
When?  Exact dates: _____________________________________________________________
What will be done with the information you collect? ________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Is this request part of a criminal investigation?		YES / NO  (Circle one)
Will this become part of a criminal investigation?	YES / NO  (Circle one)

I swear (or affirm) under penalty of perjury under the law of these united states of America that the foregoing is true and correct.  I affix my signature with prejudice and I do so voluntarily and with full intent.
(sign) ____________________________________________________________________

Refusal to sign acknowledges on your part that no authority or jurisdiction exists
with which to proceed.