EFTA01102258.pdf

U.S. Department of Justice Federal Bureau of Investigation Washington, D.C. 20535 Privacy Waiver and Certification of Identity Full Name: minty Edwitni Epstein Aliases used: Current Address 6300 Rsd Hoek Subs 63 SI. Thomas, \Argo Ma 00002 Date of Birth: Place of Birth: MISS Coady, New York Social Security Number (optional): 090-444348 CIA (Optional: Prior addresses, employments, etc.. which may assist the CBI in locating the requested information) 35*Ei We Way Pion SIC, 01040a 31480 CIA I hereby waive my right to privacy, and I authorize the ;Otto release any and all information relating to me to: (Name, address & phone of attorney or other designee) lAlvtel G. Mist.% 20 Post Plaza. 34,40 1000 &Klock, 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: EFTA01102258