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[DRAFTING DIVISIONI [STREET ADDRESS] [cITY, STATE, ZIP CODE] [MONTH, DAY, YEAR] ALL IIJFORHATIUN CONTAINED v nazrm IS UNCLASSIFIED [MIL/MRS_/Ms_] [COMPLETE NAME OF Poe] DATE as-01-~2uo&#39;: BY 65119 Dli,/I<3R!Jl92T ITITLE, IF AVAILABLE] [NAME or company] [PHYSICAL STREET ADDRESS - no P.O. Box] ECITY, STATE - no ZIP CODE] DEAR [HR./MRS./MS-1 [LAST NAME]: Under the authority of Executive Order 12333, dated December 4, 1981, and pursuant to Title 15, United States Code U.S.C.!, Section 1681u b! {the Fair Credit Reporting Act, as amended!, you are hereby directed to provide the Federal Bureau of Investigation FBI! the names, address, former addresses, places of employment, or former places of employment of the below-named consumer s!: NAME S!: ADDRESS ES!: [if available] DATE S! OF BIRTH: [if available] SOCIAL SECURITY NUMBER S!: [if available] In accordance with Title 15, U.S.C., Section 168lu a], I certify that such information is sought for the conduct of an authorized investigation to protect against clandestine intelligence activities, and that such an investigation of a United States person is not conducted solely on the basis of activities protected by the First Amendment to the Constitution of the United States. l