This Public Servant document has been used around the country to counter the anti-traditional farming movement (Government & BIG AG) and thwarting census worker’s in their invasion of your private property, with success!  Stop invasive agencies dead in their tracks.

Public Servant Questionnaire

Not as pretty but is not Adobe for those who can’t do Adobe:

These questions will help you determine what is being and their affiliates are collecting, maintaining, using or disseminating on you.Public Servant Questionnaire

Date:  _________________

1.  Name of Public Servant:______________________________________________

2.  Residence address:__________________________________________________

City:______________________________
State:_________Zip:_____________

3.  Name of department of government, bureau, or agency by which public servant is employed: ________________________________________________________

4.  Supervisor’s Name:__________________________________________________

5.  Office Mailing Address:______________________________________________

City:_____________________________
State:________
Zip:_______________

6.  Will public servant uphold the Constitution of the Untied States of America?

Yes:_____________No:______________

7.  .Did public servant provide proof of identity?   Yes:__________ No:________

Attach copy

8.  What is the nature of proof?__________________ID No_________________

Badge Number:___________

Driver’s License Number:___________________

9.  Will the public servant furnish a copy of the law or regulation which authorized this investigation?_______________________________________________

10.  Will the public servant read aloud the portion of the law authorizing the questions he will ask?    Yes:____________No:__________________________

11.  Are the citizen’s answers:

Voluntary________         Mandatory:_________

12.  Define voluntary:___________________________________________________

13.  Define mandatory:_________________________________________________

14.  Are the questions to be asked based upon a specific law or regulation?_________

15.  Or, are they being used as a discovery process?___________________________

16.  What other uses may be made of this information:
___________________________________________________________________

17.  What other agencies or affiliates may have access to this information?
________________________________________________________________

18.  Will this information be kept in a public database?________________________

19.  Will this data be kept in a private database?______________________________

20.  What will be the effect upon me if I choose not to answer any part of these questions?
___________________________________________________________________

21.  Name of person in government requesting that this investigation be made?
__________________________________________________________________

22.  Is this investigation general?________
23.  Or, is it specific?________________

Note:  By general is meant any kind of blanket investigation in which a number of
persons are involved because of geography, type of business, sex, religion, race, schooling, income, etc… By special it is meant any investigation of an individual nature in which others are not involved.

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

If yes, the identity of such third parties?_______________________________

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

Yes:__________        No: _______________

Is there a file of records, information, or correspondence relating to me being maintained by this agency?__________________________________________
Is this agency using any information pertaining to me which was supplied by another agency or government source?_________________________________

If yes, what is the agency and or source?_______________________________
Yes:_________
No:_____________________
Will the public servant guarantee that the information in these files will not be used by any other department other than the one whom he/she is employed?

Yes_________   No___________
Are you profiling individuals?  What criteria are you profiling?

__________________________________________________________________________________

A copy of this questionnaire will be kept in a private database made available to the public

 

AFFIRMATION of PUBLIC SERVANT

I, ___________________________(Please print clearly), swear (or affirm) that the answers I have given to the foregoing questions are complete and correct in every particular.

____________________________________________________________________________

Signed and Dated in ink

This signature should be witnessed by two people.  Citizen may administer an
oath if he or she so desires.

Witness:
______________________________(Please print clearly)__________________

Witness:
______________________________(Please print clearly)__________________