Personal

Information

Request

Form

TBC 350-58 (Rev. 1997/11)

	For official use only

Privacy Act

Step 1			Step 2		Step 3			Step 4
Determine which federal government institution is most likely to hold personal information about you. Decide whether you wish to submit an informal request for the information or a formal request under the Privacy Act. If you wish to make an informal request, contact the appropriate institution. The address can likely be found in Info Source publications which are available across Canada, generally in major public and academic libraries, constituency offices of federal Members of Parliament and most federal government public enquiry and service offices.			To apply for personal information about you under the Privacy Act, complete this form. Describe the information being sought and provide any relevant details necessary to help the institution find it. If you require assistance, refer to Info Source (Sources of Federal Government Information) for a description of personal information banks held by the institution or contact its Privacy Coordinator.		Forward the personal information request form to the Privacy Coordinator of the institution holding the information. The address is listed in the “Introduction” to Info Source.			When you receive an answer to your request, review the information to determine whether you wish to make a further request under the Act. You also have the right to complain to the Privacy Commissioner should you believe that you have been denied any of your rights under the Act.
Federal Government Institution
I wish to examine the information				As it is		All in English				All in French
Provide details regarding the information being sought
Method of access preferred				Receive copies of originals			Examine originals in government offices
Name of applicant
Street, address, apartment							City or town
Province				Postal Code			Telephone number
I request access to personal information about myself under the Privacy Act as I am a Canadian citizen, permanent resident or another individual, including an inmate, present in Canada
				Signature			Date
	Government of Canada	Gouvernement du Canada