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Bureaucracy Encounter Form

by Charles Curley and Claire Wolfe

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.

About The Author

Charles Curley has been working as a self-employed software engineer, writer, and instructor since 1999. To obtain more information, see

Claire Wolfe is a writer, and her most recent works are The Freedom Outlaw's Handbook, 101 Things to Do 'Til the Revolution, I Am Not a Number!, Don't Shoot the Bastards (Yet), Think Free to Live Free, and (new in Fall 2005) How to Kill the Job Culture Before It Kills You.

The opinions expressed in this article do not necessarily reflect the opinion of ILW.COM.