.mall (orginal signature needed) 0S. Departmont of Justice Federal Bureau of Investigation i Privacy Walver and Certification of identity pultenc Jeitzey E- Bpstetn Attpan axed: ; corm adieen 358 EL Brille Wav, Palm Beach, FL 33480 00 Dale or Births 1/20/1953 Placo of mnu_Kings County, New York Soda socuily Numb