Items 1 to 3: whose record
Name of individual on record, system no. and system name.
GSA3363
Privacy Act Information Disclosure Record
- Agency
- GSA
- Revision
- Rev. 6/1976
- Fillable fields
- 53
- Pages
- 1
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 3363: Privacy Act Information Disclosure Record
GSA Form 3363, Privacy Act Information Disclosure Record, is a General Services Administration form dated 6-76. The footer prints GENERAL SERVICES ADMINISTRATION, and GSA hosts it in its forms library.
It is a one-page log. The top names the individual on record and the system number and system name. Below are ten blank rows, each for one disclosure: the date, the category of record, the purpose of disclosure, the name, organization and address to whom the disclosure was made, and the initials of the persons making the disclosure.
The PDF is a scanned page and prints no instructions, filing address or legal citation. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 3363
Item 4: date
The date of each disclosure.
Item 5: category of record
The category of record disclosed.
Item 6: purpose of disclosure
Why the information was disclosed.
Item 7: recipient
Name, organization and address to whom the disclosure was made.
Item 8: initials
Initials of the persons making the disclosure.
The form has eight numbered items: three at the top and five columns repeated across ten rows.
How to complete GSA Form 3363
- 1
Name the individual
Enter the name of the individual on record in item 1.
- 2
Identify the system
Enter the system number in item 2 and the system name in item 3.
- 3
Log the disclosure
On the next open row, enter the date, the category of record and the purpose of disclosure.
- 4
Record the recipient
Enter the name, organization and address to whom the disclosure was made.
- 5
Initial the entry
The persons making the disclosure enter their initials in column 8.
The PDF prints no instructions. These steps follow the items it prints.
Why fill Form GSA3363 on indox
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Where it goes and what the form says
Where it goes
The PDF prints no filing address or routing instruction. It is a record with ten rows for entries.
What the PDF does not include
The PDF prints no instructions, OMB number, privacy notice or legal citation. GSA's page lists Current Revision Date 06/1976 and no authority or regulation.
Related forms
Who completes GSA Form 3363?
The PDF does not say who keeps it. These are the roles its items name; it is not a form the public files.
Official sources and the blank
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Questions about Form GSA3363
Who issues GSA Form 3363?
The footer prints GENERAL SERVICES ADMINISTRATION and GSA FORM 3363 (6-76). GSA hosts a copy in its forms library.
What does GSA Form 3363 record?
Disclosures from one individual's record: the date, category of record, purpose of disclosure, the name, organization and address of the recipient, and the initials of the persons making the disclosure.
Who initials each entry?
Column 8 is headed Initials of Persons Making Disclosure.
Where is GSA Form 3363 sent?
The PDF prints no address or routing instruction for the form.
How many disclosures fit on one form?
The form has ten rows for entries.