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Reserved.
EMERGENCY DISCLOSURE FORM
Pursuant to Title 18 U.S.C. §2702 (b)(8) and §2702 (c) and the Facebook privacy
policy, Facebook may exercise its discretion in providing relevant data after
reviewing the provided information below. Please provide as much
information in order to enable the Security team to conduct an appropriate
search.

1. Describe the emergency and why it poses a risk of serious physical injury or
death to a specific person or group of people.

2. When do you expect this emergency to take place and why do you think that
it will happen at this particular time?

3. What information are you seeking and how will it assist in preventing serious
physical injury or death?

4. Have you obtained or tried to obtain legal process to compel the disclosure
of this data? If not, please explain why. YES NO

I, _________________________, attest that the above-mentioned facts are

true and accurate to the best of my knowledge.

_____________________________ ______________________________
Signature and Title and Printed Name Date