|FORMS: 14.12 REQUEST TO CORRECT/AMEND ERRONEOUS IRS ELECTRONIC RECORDS UNDER THE PRIVACY ACT|
|RIGHT click here for the Word 97 version of this document|
Certified Mail # 7002 0860 0007 XXXX XXXX
(Include the Requester's name and this number in your reply)
April 28, 2003
RE: Account No. xxx-xx-xxxx used to identify and maintain your system of records.
PRIVACY ACT REQUEST TO AMEND RECORDS
Dear Disclosure Officer:
This is a request under the PRIVACY ACT of 1974 and IRM [1.3] 18.5 (08-19-1998) titled “Requests to Amend Records” about myself maintained by your agency.
I believe the following is not correct (identify specific record and information within the record optionally with copies enclosed)
The information is not accurate OR relevant OR timely OR complete because supporting evidence may be included. Enclosed are documents that show that the information is incorrect.
I request that the information be deleted – why. OR Changed to read - Provide evidence of the validity of the new or additional information should be included.
This “PRIVACY ACT REQUEST TO AMEND RECORDS” and all attached documents must be filed as a permanent part of any administrative hearing and any IRS/IDA/AIMS/IMF and 23C record(s) regarding NAMEÓ, xxx-xx-xxxx. If such record(s) have/has been moved, deleted or substituted, this demand still applies.
If agency refuses to make changes herein requested, provide the following (1) the agency written refusal to amend the record; (2) the reason with supporting documents for refusing to amend the records; (3) the procedures for requesting a review of the denial; and (4) provide the name and address of the official responsible for conducting the review.
Name, Requester. All rights reserved.
Enclosure: Photocopy of Drivers License enclosed to provide proof of Identification.