|FORMS: 13.3 PUBLIC SERVANT QUESTIONAIRE|
|RIGHT click here for the Word 97 version of this document|
Below are copies of a questionnaire that can be invoked against government agents that are asking you for information. It was first written in 1983 by Mr. Lynn Johnston, and has received praise from both Jews for the Preservation of Firearms Ownership (who can be reached at 2872 So. Wentworth, Milwaukee, Wisconsin, (414) 769-0760) and the Lawyers Second Amendment Society (18034 Ventura, No. 329, Encino, California, (818) 734-3066).
The first version is general and could, I suppose, be invoked against any government agent that's requesting information from you. You may even want to keep a copy in your car and invoke it if you get pulled over. Question 16 is different in the second version below. This is designed to be invoked against a tax agency (i.e. IRS).
I've spoken to Richard McDonald of the State Citizens' Service Centers (BBS: (818) 888-9882) and he said that it's working pretty good for those who're using it. Anyone interested in his work on federal and state income taxes can call (818) 762-5412 for more information.
Public Servant Questionnaire
This questionnaire must be filled-out by any public servant before he can ask the citizen any question. This is authorized by federal law, including the Privacy Act, 5 U.S.C. 552a, 88 Stat. 1896, et seq., 1974.
1. Public servant's full legal name:
2. Public servant's residence address:
3. Name of agency:
4. Name of supervisor and office address:
5. Will public servant uphold the constitution of the United States?
6. Did public servant provide proof of identity?
7. ID number:
Bonding agency and number:
8. Will public servant furnish a copy of the law or regulation that authorizes the action being taken or information requested in this case?
9. Will public servant read aloud that portion of the law authorizing the questions asked?
10. Are answers voluntary or mandatory?
11. Are the questions being asked based upon a specific law or regulation, or are they a discovery process?
12. What other uses may be made of this information?
13. What other agencies may have access to this information?
14. What will be the effect upon me if I should not choose to answer any or all of these questions?
15. Name of person in government requesting this information:
16. Is this investigation general or special?
Note: by ‘general,’ it means any kind of blanket investigations in which a number of persons are
involved because of geography, type of business income, etc. By ‘special,’ it means any investigation
of an individual nature in which others are not involved.
17. Have you consulted, questioned, interviewed, or received information from any third party relating to this matter?
18. If yes, give identity of all such third parties:
19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the information which you seek?
20. Is there a file of records, information, or correspondence relating to me being maintained by this agency?
21. Is this agency using any information on me which was supplied by another agency or government source?
22. Will the public servant guarantee that the information in these files will not be used by any other department other than the one by which he is employed?
I hereby sign and affirm under the penalty of perjury that the answers are true and correct in every particular.
Signature of public servant
Notice: If any request for information relating to me is received by any person or agency, you must advise me in writing before releasing such information. Failure to do so may subject you to possible civil or criminal action as provided by this act or other law(s).