Here is the template from Rahul Kumar's PDF file
FOIPA Template : Do I file for myself only or file for my wife who is the dependent.
Use this as a template to file your FOIPA request. Modify it to suit your information and fax it in to the FBI. Contact Debbie Beatty at (202) 324 6182 for more info
Make sure you send a Privacy Act request to check if FBI has a record in their Central Records System. It is important to see if there is a record or not. If you get a ‘No-Records” response and your name check is pending for a long time, you can take this information to Mr. Hardy/Mr. Hooton
To:
David M. Hardy, Chief
Record/Information Dissemination Section
Federal Bureau of Investigation
935 Pennsylvania Avenue, N.W.
Washington, D.C. 20535
Fax: (202) 324-3752
Sub: PRIVACY ACT REQUEST
Dear Mr. Hardy:
Under the Freedom of Information Act, 5 U.S.C. section 552 and the Privacy Act, 5 U.S.C. section 552a, please furnish me with copies of all records about me indexed to my name or my identifying information, maintained in the Central Records System (CRS).
To help identify information about me in your records systems and/or programs, I am providing the following identifying information:
Full Name: John Doe
Date of Birth: January 1, 1981
Place of Birth: Tokyo, Japan
Social Security Number: 123-45-6789
Current Address: 123 My street, City, State Zip
Home Phone Number: 555-555-5555
If you have any questions about handling this request, you may phone me at 555-555-5550 (day or evenings). Please respond to: John Doe, 123 My street, City, State Zip.
Sincerely,
Signature
John Doe
Pursuant to 28 U.S.C. 1746, I certify under penalty of perjury that the foregoing is true and correct and that I am requesting release of my records to myself.
Executed on [date].
Signature