EFTA00726668.pdf

Federal Bureau of Investigation - Privacy Waiver and Certification of Identity Page 1 of 1 COM0010. SIM and meh (WOW sigeolute modem US. Daparonent ofJusdce Federal Bureau ofIniresfigation Privacy Waiver and Certification of Identity Fla Nem Jeffrey E. Epstein name uses' CunzetAddrest 358 R1 Ari 1 to Way. Palm Beach, FL 33480 osioreirer 1/70/1951 Ptoei EWE Ki rigs County, New York soda soapily Meeker Oneonta ncm-44 -114R (ombnd.Not eseeseyonnyloymerie. et. which may Neil the FM biota the requested Inhandlon) I hereby mine Mifflin to ply, end I euthertte the Fano age ee any and ell Intonation Meting to me it (Nam., othlass a phone of names. or ohm designee) 20 Park P 1000, 02116 - 617 227 3700 Under pinata abed atom a and underytend owl an fahfeetion el the otelommapolehoMe mat the al nue it USW WOK reel mere men $11:4000 of by Imeatemeent AN Me Ikea hes yam. et WC re0undn0 et otnear0 on, mcedre) under the proddonotl relax U.S.C. Secienel end thal 552e (0(31ea a nesdonteener end by a ano el nol mete than $SA00. Strinelksce: Dab: 15 14/ 8 http://foia.fbi.gov/waiver.htm 12/29/2009 EFTA00726668 Federal Bureau of Investigation - Privacy Waiver and Certification of Identity Page 1 of I Complete. elan, end mall (original bonatue needed) U.S. Department of Justice Federal Bureau ofInvestigation Privacy Waiver and Certification of Identity Full Nome: Jeffrey E. Epstein eases used: Current Address: Date of BM Place el BUM: Soda) seaway Number (optimal): (Optional. odor addressee. employments. elt, veldt may swat the COI in locating the niqueSted Inernallon) hereby waive my right to prIvacy, and I authorize the FBI to release any end all Infomtellon relating la ma to: (Name, address a phone of attorney or other designee) —M -errt- i-n—G —terertirlyerrrt 20 Park Plempa I amSuite 1_910)24. Boston, MA 02116 - 617 227 3700 under pasty or p•dury. natty a the parson det1. Sams Codtt (U.S.C.). Seam loot 0 and uredmstend mat any fatuneabon of (Its Statement Is punishable under me PrVASIOAS of TWo IS. Untied by a Ina Of not more than 510.O00 or by irredsormerd of not mom bun five years. or both: and that rocwasuap or obtaining any recordist ander false pretense* It punishable mar the provisions el TM S. U.S C.. Section 552a (1)(3) as d MiSICITICIMOl and by a fine of not mere than $5,020. 5k:tuba° Dale: http://foia.fbi.gov/waiver.hun 12/29/2009 EFTA00726669  Federal Bureau of Investigation - Privacy Waiver and Certification of Identity Page 1 of 1 Conialeie. sign. ad mat (coDnal sarature needed) U.S. Department of Justice Federal Bureau of Investigation Privacy Waiver and Certification of Identity Full Name. Atlases used Current Address Data el Binh Place of BMA Scrod Securely Number (option:0h' (Optional: Nor addresses. employments. at. wheli may assist the FBI In Iccaiing the requested InIcenation) I hereby waive my right to privacy: and 1 authorize the FBI to release n ny end all Information relating to me to: (Narne: address 8 phone of attorney or other designee) Under penally of pc/May.1 heratry declare that I am the person described above and omen-nand that any falificelion of Um statement is punishable under No ;novo:owe ca Toile la. IMMO Stales Cede (U S.C.). Section 1001 by a fine of not more than 510.000 of by Irrprlsonment °Snot more than five yea's. Cr bah: and that requesting Or Oblaiikig any record(s) under false defenses is panishaale under the prinetiontr d Bee S. U.S C.. Section S520 (ice) as a TiSdellIllanOf and by a Frio of not mato than 5.000 Signature: Date http://foia.fbi.gov/waiver.htm 12/29/2009 EFTA00726670