AUTHORIZATION TO OBTAIN CONSUMER (Credit) REPORT



AUTHORIZATION TO OBTAIN CONSUMER (Credit) REPORT

Carefully read this authorization for release of information, then sign and date in ink.

|PRINTED NAME |ADDRESS (Include street, apt. number, city, state and ZIP code) |

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|      |      |

|SIGNATURE | |

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|DATE | |

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|      | |

|SOCIAL SECURITY NUMBER |TELEPHONE NUMBER | |

| | | |

| | | |

|      |      | |

FORM G7185 FEB 98

NSN: 7540-FM-001-5635

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PRIVACY ACT STATEMENT: Auth: GNSA06, G华ㅁⰰ倠扵䰮‮㘸㌭ⰶ愠摮倠扵䰮‮㠸㈭〹※华鉁⁳求湡敫⁴潒瑵湩⁥獕獥映畯摮愠⁴㠵䘠摥‮敒⹧ㄠⰰ㌵‱ㄨ㤹⤳愠灰祬琠桴獩椠普牯慭楴湯‮䄠瑵⁨潦⁲敲畱獥楴杮匠乓›佅㤠㤳⸷†牐湩楣慰畐灲獯㩥琠扯慴湩椠普牯慭楴湯眠楨档眠汩獡楳瑳匠捥牵瑩⁹敓癲捩獥椠敲捡楨杮愠湩潦浲摥搠捥獩潩敲慧摲湩⁧畳瑩扡汩瑩⁹潦⁲⁡敳畣楲祴挠敬牡湡散‮䐠獩汣獯牵⁥景琠敨匠乓椠⁳潶畬瑮牡⹹†楄捳潬畳敲漠⁦污瑯敨⁲湩潦浲瑡潩獩洠湡慤潴祲‮䘠楡畬敲琠牰癯摩⁥慭摮NSA10, Pub.L. 86-36, and Pub.L. 88-290; NSA’s Blanket Routine Uses found at 58 Fed. Reg. 10,531 (1993) apply to this information. Auth for requesting SSN: EO 9397. Principal Purpose: to obtain information which will assist Security Services in reaching an informed decision regarding suitability for a security clearance. Disclosure of the SSN is voluntary. Disclosure of all other information is mandatory. Failure to provide mandatory information may result in an adverse suitability determination. Failure to provide SSN may delay processing thereby delay a determination of suitability.

Instructions for Completing this Release

This release form authorizes the investigator to obtain a copy of your consumer (credit) report from a consumer reporting agency (credit bureau) pursuant to the provisions of the Fair Credit Reporting Act of 1970, as amended (15 U.S.C. Sec 1681 et seq.). The Federal agency or department receiving the report will use the consumer report to assist in its adjudication of whether you satisfy the criteria to receive access or continued access to classified national security information. Your signature is required before this release becomes valid.

AUTHORITY TO RELEASE INFORMATION

I hereby authorize any investigator, special agent, or other duly accredited representative of the authorized Federal agency or department conducting my background investigation, bearing this release or copy thereof that shows my signature, to obtain a copy of my consumer report as that term is defined in the Fair Credit Reporting Act (FCRA) of 1970, as amended (15 U.S.C. Sec. 1681 et seq.) I understand that my consumer report will be used to assist in determining whether I satisfy the criteria to receive access or continued access to classified national security information. Furthermore, I understand that, if information in my consumer report leads to the Federal agency or department taking action adverse to me as defined in the FCRA, that I will be given an opportunity to appeal the action consistent with applicable law, executive order, and agency or department regulation. However, I understand that I may not receive advance notice of an adverse action based in part on the consumer report if the Federal agency or department has reason to believe that advance notification will result in endangering the life or physical safety of any person; flight from prosecution; destruction or tampering with evidence; intimidation of potential witnesses; compromise of classified information; or otherwise seriously jeopardize an investigation or official proceeding or unduly delay an ongoing official proceeding.

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