Form 3170-XXXX CFPB FBI Name Check Form

The Consumer Financial Protection Bureau
PRIOR TO COMPLETING THIS FORM, PLEASE BE SURE YOU HAVE REVIEWED THE TERMS OF THIS AGREEMENT.

By providing the information herein and by signing this waiver, I voluntarily authorize the Internal Revenue Service to release the
tax return and return information indicated below. The return and return information will be used concerning my appointment or
employment by the United States Government. This waiver is made pursuant to 26 U.S.C. 6103(c), which permits the release of
return and return information, which would otherwise be confidential, to my designee.
I designate that the Internal Revenue Service release return and return information to:
Kathleen Horan, Personnel Security Program Manager

The information I am consenting to release is:
1.

2.
3.
4.
5.

Have I failed to file a Federal income tax return for any of the last three (3) years for which filing of a return might have
been required? If the filing date for the most recent required return has not yet lapsed on the date the IRS receives this
waiver and IRS records do not indicate a return filing for the most recent required return, the “last three years” will
mean the three years preceding the year for which returns are currently being filed and processed.
Were any of the returns in #1 filed more than forty-five (45) days after the due date for filing, determined with regard to
any extension(s) of time for filing?
Have I failed to pay any tax, penalty, or interest liability during the current or last three calendar years within forty-five
(45) days of the date of which the IRS gave notice of the amount due and request for payment?
Am I now or have I ever been under investigation by the IRS for possible criminal offenses?
Has any civil penalty for fraud been assessed against me during the current or last three (3) calendar years?

If the information, which is to be released, includes a “Yes” answer to any of the above five questions, I authorize the Internal
Revenue Service to release any information pertaining to that question.
THE CANDIDATE MUST SIGN AND DATE THE BOTTOM OF THIS FORM.
MY NAME: ________________________________________________
MY SSN:

____ ____ ____ - ____ ____ - ________ ____ ____

PHONE NUMBER(S):

HOME: (______) ____________________ WORK: (______) ______________________

CURRENT ADDRESS:

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

IF MARRIED AND FILED A JOINT RETURN:
SPOUSE NAME:

_____________________________________________________

SPOUSE SSN:

____ ____ ____ - ____ ____ - ____ ____ ____ ____

NAMES AND ADDRESSES SHOWN ON RETURNS FOR THE LAST THREE (3) YEARS (IF DIFFERENT FROM ABOVE)
YEAR

NAME

ADDRESS

_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
DATE: __________________________________________
WAIVER INVALID UNLESS THE DATE IS
HAND-WRITTEN BY TAXPAYER AND RECEIVED BY
THE IRS WITHIN 120 DAYS OF THIS DATE

_________________________________________________
SIGNATURE OF THE TAXPAYER AUTHORIZING THE
DISCLOSURE OF RETURN/RETURN INFORMATION

Privacy Act Statement
We ask for the information on this form to establish our right to query the FBI to perform an “FBI Name
Check.” This information will be used concerning your appointment or employment for the United States
government.
The information will be used by and disclosed to employees, contractors, agents and others authorized by
the Consumer Financial Protection Bureau to receive this information to assist in related activities. The
information may also be disclosed:






to a court, magistrate, or administrative tribunal in the course of a proceeding;
to another federal or state agency or regulatory authority,
to the office of the President; to a member of Congress;
to the public in the form of names, affiliations, and other pertinent biographical information of
board or committee members and;
pursuant to the CFPB’s published Privacy Act system of records notice, CFPB-016, CFPB
Advisory Boards and Committees.

The collection of this information is authorized by Public Law 111-203, Title X, sections 1011, 1012,
1014, codified at 12 U.S.C. §§ 5491, 5492, 5494.
You are not required to submit your Social Security number or provide any other identifying information.
However, not doing so may result in your non-selection as a prospective advisory board member, panel,
committee or other similar group membership.
Paperwork Reduction Act
This information collection will be used to allow the CFPB to ask the FBI to perform a “name check”
procedure on the above named person, checking their name against the FBI’s files such as investigation and
criminal records. The information collection is voluntary, and it will be treated in accordance with the
Privacy Act Statement above. According to the Paperwork Reduction Act of 1995, an agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this collection is 3170-XXXX. It expires
on MM/DD/YYYY. The time required to complete this information collection is estimated to average
approximately 10 minutes per response, including the time for reviewing any instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information.

The Consumer Financial Protection Bureau (CFPB) prohibits discrimination in all its programs and
activities on the basis of race, color, national origin, gender, religion, age, political beliefs, sexual
orientation, marital or family status, parental status or protected genetic information. (Not all prohibited
bases apply to all programs.) Persons with disabilities who require alternative means of communication
of program information (Braille, large print, audiotape, etc.) should contact Liza Strong, Labor and
Employee Relations, Office of Human Capital. To file a complaint of discrimination, contact the
Treasury Department at 202-622-9252. CFPB is an equal opportunity provider and employer.