EFTA01104754.pdf

U.S. Department of Justice Federal Bureau of Investigation Washington, D.C. 20535 Privacy Waiver and Certification of Identity Full Name: Jeffrey Edward Ephion Aliases used: Current Address: 6300 RS Honk. Sub 83 SI. Thomas, Virgin Islands. 00602 Date of Birth: Place of Birth: Kings copy. Now York Social Security Number (optional): CIA (Optional: Prier addresses, employments, etc., which may assist the g84 in locating the requested information) 354 Et Bits Way 9 East 714 Street Pate Ban. notcla 33460 New VOrk, Now York. 10021 CIA I hereby waive my right to privacy, and I authorize the gal to release any and all information relating to me to : (Name, address & phone of attorney or other designee) Mann a Weinberg TO Park Playa. Solo MOD tioinn. MA 02116 Under penalty of perjury, I hereby declare that I am the person described above and understand that any falsification of this statement is punishable under the provisions of Title 18. United States Code (U.S.C.). Section 1001 by a fine of not more than $10,000 or by imprisonment of not more than five years, or both: and that requesting or obtaining any record(s) under false pretenses is punishable under the provisions of Title 5, U.S C.. Section 552a (i)(3) as a misdemeanor and by a fine of not more than $5,000. Signature: Date: EFTA01104754