HTML version of the form: Personal Information Request Form
Protected B (when completed)
Personal Information Request Form
This form may be used to request your right to access your personal information held by government institutions that are subject to the Privacy Act. Please see instructions before completing this form. Alternatively, you may make a request via the ATIP Online Request Service (atip-aiprp.tbs-sct.gc.ca), or submit a request in writing to the government institution from which you are requesting personal information.
Privacy notice statement
The personal information provided on this form is collected and protected under the provisions of the Privacy Act. It is retained and used as described in Personal Information Bank PSU 901 by the institution to which this form is submitted. Any questions about the collection, use or disclosure of this information should be directed to the Access to Information and Privacy Coordinator of the institution to which this form is submitted. The information is used to process and respond to formal requests made under the Privacy Act, including subsequent requests for corrections, complaints, investigations and judicial review when applicable. Failure to provide this information may result in the inability to process your request. You have the right to the correction of, access to, and protection of your personal information under the Privacy Act. You have a right to complain to the Office of the Privacy Commissioner of Canada regarding the handling of your personal information request.
- I acknowledge the privacy notice statement above.
Personal information
- I am:
- A Canadian citizen or permanent resident
- A foreign national present in Canada
- A foreign national outside of Canada
- Family name:
- Given name(s):
- Current address (address number, apartment number, street, city, province, postal code):
- Telephone, E-mail, Fax:
Correspondence
- Please indicate your preferred language of communication with the government institution
- English
- French
- Please indicate your preferred method of communication with the government institution:
- Telephone
- Letter
- Fax
Information about your request
- Government institution from which you are requesting personal information:
- I would like the requested information:
- As it is
- In English
- In French
- Please describe your request, including specific details such as date or date ranges, and details that may help the institution to find your information more quickly.
- I would like to access the requested information:
- As electronic copies
- As paper copies
- In person at government offices
Attestation (please select only one option)
- If you have checked off Box 2, please submit consent of the Individual(s).
- If you have checked off Box 3 or 4, please submit authorization or legal documentation to
demonstrate that you are entitled to make a request for another Individual.
- I am requesting personal information about myself
- I am requesting personal information and it may contain another individual’s personal information and I have their consent
- I am requesting personal information on behalf of another individual and I am authorized to do so
- I am requesting personal information of another individual who is deceased, and I am authorized to do so
- Date (yyyy-mm-dd):
Supplemental information
Please attach along with this form copies of your identity documents.
Please note that the institution may contact you to verify your identity and to confirm that your request meets the requirements of the Privacy Act, Privacy Regulations, and associated policies.
If the institution is unable to verify your identity, despite making best efforts to do so, your request may not be processed.
Personal Information Request Form - Instructions
A. Language
This form must be completed in English or in French.
B. Government institution
Determine which federal government institution is most likely to hold personal information about you using the publication Information about programs and information holdings
C. Obtaining personal information
To obtain your personal information under the Privacy Act, either make a request via the ATIP Online Request Service or complete this form. Describe the information being sought and provide relevant details necessary to help the institution find it. If you require assistance, refer to Information about programs and information holdings for a description of records held by the institution or contact the institution’s Access to Information and Privacy Coordinator.
For any additional questions about your request, please contact the ATIP coordinator of the Government Institution administering your request.
D. Identity
The institution may contact you to verify your identity. More than one piece of identification may berequired. If your documents are in a language other than English or French, a certified translation of the document in English or in French maybe required. The institution may also ask you to provide any additional documentation that they may need to verify your identity.
E. Consent, authorization, and legal documentation
A request made may also contain the personal information of another individual, such as family member(s). Should you wish, you may obtain consent and submit the necessary documentation along with your request. This may permit the department to release their information and will provide you with more information in response to your request. You may wish to include the Consent for a Personal Information Request Form, which contains all the necessary information to do so.
Should you wish that someone else, known as the “authorized representative” to make a request for your personal information on your behalf, you must authorize them to do so in writing. You may wish to include the Authorizing a Personal Information Request to be Made on Your Behalf Form, which contains all the necessary information to do so.
If you are requesting personal information on behalf of another individual, please complete the personal information request form with your contact information and provide their information in the “Information about your request” field. You will need to provide supporting documentation that you have power of attorney or are the legal representative for a deceased person.
F. Submission
Please send this form to the Access to Information and Privacy Coordinator of the appropriate institution.
G. Complaints
Should you have any questions about the response to your request, please contact the Access toInformation and Privacy Office of the institution. If you are not satisfied with how your personal information request is processed, with the information you receive or with how your personal information has been handled or protected, you may make a complaint to the Office of the PrivacyCommissioner of Canada.
TBS/SCT 350-58E (Revised 07/2022)