[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-194904-105":53,"doc-detail-194904-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","privacy-act-consent-form-state-05","Privacy Act Consent Form - State-05","","Privacy Act of 1974 and related regulations protect personal information maintained by the Department of State and its embassies and consulates. This form enables individuals to specify with whom the Department may share case-related information beyond routine circumstances, where consent is voluntary. It requests contact details to support outreach and asks respondents to select eligible recipients such as family, friends, employer, attorney, congressional offices, media, and other assisting parties. It also collects disclosure preferences and requires informed, voluntary consent with signature and identifying details.",{"@graph":63,"@context":123},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/privacy-act-consent-form-state-05/194904/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/privacy-act-consent-form-state-05/194904.png","ImageObject",442,249,{"name":88,"@type":89},"Logic","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115,119],{"name":106,"@type":107,"acceptedAnswer":108},"What is the purpose of this form?","Question",{"text":109,"@type":110},"The form lets you tell the Department of State with whom it may share relevant information about your case beyond common circumstances. You may provide contact information to help reach those individuals or organizations.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Is providing the requested information mandatory?",{"text":114,"@type":110},"Providing the information is voluntary. Without it, the Department may find it more difficult to assist you in a way consistent with your wishes.",{"name":116,"@type":107,"acceptedAnswer":117},"Which parties can you consent to for information sharing?",{"text":118,"@type":110},"You can consent to sharing with parties you select, including family, friends, employer, attorney/representative, congressional offices, media, and other parties positioned to assist you.",{"name":120,"@type":107,"acceptedAnswer":121},"What are the requirements for consent and signature?",{"text":122,"@type":110},"You must indicate consent for release of information in accordance with stated rules and practices, and complete the electronic or ink signature. The form also requires identifying details such as full name and date of birth.","https://schema.org",{"og:url":78,"og:type":125,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":127,"canonical":78},"index,follow",{"doc_id":129,"site_id":56},194904,1788443779,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":88,"user_avatar":134,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":140,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":61,"update_tm":130,"read_time":9},1099513958762,"https://ap-avatar.wpscdn.com/avatar/1000023916a998db790?x-image-process=image/resize,m_fixed,w_180,h_180&k=1784791008015729253","| Safeguarding your privacy is an integral part of the consular mission. The Privacy Act of 1974 and related rules provide a range of protections for personal information that the Department, including its embassies and consulates worldwide, maintains about you. The Act also permits-but does not require-the Department to share such information in various established common circumstances, such as when we engage with U.S. and foreign government authorities in connection with your case and when we work with various entities and individuals in emergency situations.\u003Cbr>The purpose of this form is to allow you to tell the Department of State with whom you would like us to share information about your case, outside of the common circumstances mentioned above. If possible, you can assist us in reaching these individuals or organizations by providing contact information. Providing this information is voluntary, but without it the Department may find it more difficult to assist you in a manner consistent with your wishes.\u003Cbr>Further information about our privacy rules and practices is available at [foia.state.gov](foia.state.gov) and the State-05  Federal Register Overseas Citizens Services  Records notice.\u003Cbr>Authority: 5 U.S.C. 552a (Privacy Act), 22 U.S.C. 2656 (Management of Foreign Affairs), 22 U.S.C. 3904 (Functions of Service), Vienna Convention on Consular Relations. |  |  |\n| --- | --- | --- |\n| Are there particular individuals to whom you would like the Department of State to provide relevant and appropriate information about your case/situation? If so, please provide name(s), relationship, and contact details below. |  |  |\n| Name (Last, First, Middle) | Relationship/Affiliation | E-Mail / Phone (specify mobile or landline) / Street Address |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\n\n| In addition to any individuals you have listed, do you consent to the Department of State providing relevant information about your case/situation to (please check all that apply):\u003Cbr> Family  Friends  Employer\u003Cbr> Attorney/representative  Congressional offices  Media\u003Cbr> Other parties in a position to assist you |  |  |\n| --- | --- | --- |\n| If there is anything about your case/situation (e.g. , health status, location, contact details) that you particularly wish, or do not wish, to be disclosed, please specify below. |  |  |\n| I understand the foregoing and voluntarily consent to release of information about my case in accordance with the rules, practices, and preferences set out above. I declare under penalty of perjury under the laws of the United States of America that I am the person named below.\u003Cbr>Signature: Electronic signature (retyping your name in this box using an electronic method) is as acceptable as signing with pen/ink and paper. |  |  |\n| Full Name (Printed) |  | Date of Birth (mm-dd-yyyy) |\n| Signature (Ink, Typed) |  | Date (mm-dd-yyyy) |\n| | If you are completing this form on behalf of a minor, please check the box and state the minor's full name and your legal relationship: |  |","cbCaiqTBK160StLs","https://ap.wps.com/l/cbCaiqTBK160StLs","pdf",30113,"English","# Privacy and purpose of the consent\n## Voluntary information sharing and common circumstances\n## Recipients you consent to share with\n## Disclosure preferences and release consent\n## Signature and personal details","[{\"question\":\"What is the purpose of this form?\",\"answer\":\"The form lets you tell the Department of State with whom it may share relevant information about your case beyond common circumstances. You may provide contact information to help reach those individuals or organizations.\"},{\"question\":\"Is providing the requested information mandatory?\",\"answer\":\"Providing the information is voluntary. Without it, the Department may find it more difficult to assist you in a way consistent with your wishes.\"},{\"question\":\"Which parties can you consent to for information sharing?\",\"answer\":\"You can consent to sharing with parties you select, including family, friends, employer, attorney/representative, congressional offices, media, and other parties positioned to assist you.\"},{\"question\":\"What are the requirements for consent and signature?\",\"answer\":\"You must indicate consent for release of information in accordance with stated rules and practices, and complete the electronic or ink signature. The form also requires identifying details such as full name and date of birth.\"}]","Privacy Act Consent Form - State-05 | PDF"]