◆ SpookStack

__FD-484 (95-75) Pa INSTRUCTIONS: Please sign and return one of the two enclosed copies This is to advise you in conformance with the Privacy Act of 1974 that the information solicited from you by personnel of the FBI is needed to complete background inquiries required by the authority granted in Title 28, Part O, Subpart P, paragraph 0.85, subparagraph C, Code of Federal Regulations. The furnishing of this information is voluntary on your part. The information re- quested from you is needed to complete a background inquiry. The information furnished by you and the results of inquiry will be used to determine your eligibility for access to FBI space. You should be aware that wilfully making a false statement or concealing a material fact could be a basis for refusing you access to FBI space, and may constitute a violation of Section 1001, Title 18, United States Code. Mticf, RO, /7f7? Date FBI/DOJ