PUBLIC EMPLOYEE QUESTIONAIRE

Public Law 93-579 states in part: "The purpose of this Act is to provide certain safeguards for an individual against invasion of personal privacy by requiring Federal agencies...to permit an individual to determine what records pertaining to him are collected, maintained, used, or disseminated by such agencies."

The following questions are based upon that act and are necessary in order that the individual may make a reasonable determination concerning divulgence of information to this agency.  Separate sheets may be used for answers if insufficient space is provided here.

Name of individual being examined:

     ________________________________________________________

1.  Name of public employee

     ________________________________________________________

2.  Residence of public employee

     ________________________________________________________

     City_______________________________State______Zip_________

3.  Name of department, bureau, or agency by which public employee
   is employed

     ________________________________________________________

     Supervisor's name

     ________________________________________________________

4. Mailing address of department, bureu, or agency

     ________________________________________________________

     City_______________________________State______Zip_________

5. Will public employee uphold the Constitution of the United States?

     Yes _____        No _____

6. Did public employee furnish proof of identity?

     Yes _____        No _____

7. What was the nature of proof?

     Yes _____        No _____

8. Will public employee furnish a copy of the law or regulation which authorizes this investigation?

     Yes _____        No _____

     If yes, when? ____________________________________________

9. Will the public employee read aloud the portion of the law authorizing the questions he will ask?

     Yes _____        No _____

     If yes, when? ____________________________________________

10. Are the answers to the questions voluntary or mandatory?

     Voluntary _____     Mandatory _____

     If mandatory, please list the mandatory questions on a separate sheet. 

     11. Are the questions to be asked based upon a specific law/regulation, or are they being used as a discovery process?

     Yes _____        No _____

     IF yes, please list the law/regulation(s):

     ________________________________________________________

12. What other uses may be made of this information?

     ________________________________________________________

13. What other agencies may have access to this information?

     ________________________________________________________

If access is permitted, when will access be provided?

     ________________________________________________________

14. What will be the effect upon the individual if any part or all of these questions are refused?

     ________________________________________________________

15. Name of person(s) in or out of government requesting/ordering that this investigation be made:

     ________________________________________________________

16. Is this investigation 'general' or is it 'special'?

     ________________________________________________________

17. Have you consulted, questioned, interviewed, or received information from any third party relative to this investigation?

     Yes _____        No _____

18. If so, identify and name each of the third parties

     ________________________________________________________

19. Do you reasonably anticipate either a civil or criminal action to be initiated or pursued based upon any of the requested information?

     Yes _____        No _____

     What is the probable cause for the investigation?

20. Is there a file of records, information, or correspondence relating to the individual being maintained by this agency?

     Yes _____        No _____

     If yes, which?

     ________________________________________________________
21. Is this agency using any information pertaining to the individual which was supplied by another agency or government source?

     Yes _____        No _____

If yes, which?

     ________________________________________________________

22. May the individual have a copy of that information?

     Yes _____        No _____

     If yes, when?

     ________________________________________________________

     If no, why not?

     ________________________________________________________

23. Will the public employee guarantee that the information in these
files will not be used by any other department other than the one
by whom he is employed?
 
     Yes _____        No _____

     If yes, when?

     ________________________________________________________

     If no, why not?

     ________________________________________________________

If any request for information relating to this investigation is received from any person or agency, public employee must advise individual in writing before releasing such information. Failure to do so may result in a civil or criminal action as provided by the act.

I declare (or affirm) under penalty of perjury that the answers I have given to the foregoing
questions are true and correct in every particular.

Investigator: ___________________________       Date: ________/_________/_____________

Witness:_______________________________   Witness: _______________________________

Authorities for Questions

1,2,3,4   In order to be certain the individual knows exactly who you are giving the information to. Residence and business addresses are needed in case of service of process in a civil or criminal action.

5  All public employees have taken a sworn oath to uphold and defend the constitution.

6,7   This is standard procedure by government agents and officers.  See Internal Revenue Manual, MT-9900-26, Section 242.133.

8,9,10  Title 5 USC 552a, paragraph (e) (3) (A)

11  Title 5 USC 552a, paragraph (d) (5), (e) (1)

12,13  Title 5 USC 552a, paragraph (e) (3) (B), (e) (3) (C)

14  Title 5 USC 552a, paragraph (e) (3) (D)

15  Public Law 93-579 (b) (1)

16  Title 5 USC 552a, paragraph (e) (3) (A)

17,18  Title 5 USC 552a, paragraph (e) (2)

19  Title 5 USC 552a, paragraph (d) (5)

20,21  Public Law 93-579 (b) (1)

22  Title 5 USC 552a, paragraph (d) (1)

23  Title 5 USC 552a, paragraph (e) (10)

14th Amendment:  "Both before and after the Fourteenth Amendment to the federal Constitution, it has not been necessary for a person to be a citizen of the United States in order to be a citizen of his state." Supreme Court of Maryland, Crosse v. Board of Elections, (1966) 221 A.2d. 431, 433

Miscellaneous

"The word 'shall' in a statute may be construed to mean 'may', particularly in order to avoid a constitutional doubt." Fort Howard Paper Co. v Fox River Heights Sanitary Dist., 26 NW 2d 661

"If necessary, to avoid unconstitutionality of a statute, 'shall' will be deemed equivalent to 'may.'" Gow v Consolidated Copper Mines Corp., 165 Atl 136.

"'Shall' in a statute may be construed to mean 'may' in order to avoid constitutional doubt." Grover Williams College v Village of Williams Bay, 7 NW 2d 891.

"Because of what appears to be a lawful command on the surface, many citizens, because of their respect for what only appears to be law, are cunningly coerced into waiving their rights due to ignorance." U.S. vs. Minker, 350 U.S. 179 at 187