Fair Credit Report Act

Information Provided Concerning the Disclosure
and Authorization Pertaining to Consumer Reports pursuant to the
Fair Credit Reporting Act (FCRA)
A required component of your investigation for employment in a moderate or high risk position or National Security
Clearance is an inquiry with a credit bureau. Under the provisions of the Fair Credit Reporting Act (15 § U.S.C. 1681 b),
Section 604, (b)(2)(A) and (B), Permissible Purposes of Consumer Reports, we may not obtain the report unless:

• "a clear and conspicuous disclosure has been made in writing to the consumer at any time before the

report is procured or caused to be procured, in a document that consists solely of the disclosure, that a
consumer report, may be obtained for employment purposes; and

• ''the consumer has authorized in writing the procurement of the report by that person.''
The attached Disclosure and Authorization Pertaining to Consumer Reports Pursuant to the Fair Credit Reporting
Act must be signed so we can conduct an inquiry with a credit bureau and complete your investigation. Failure to
complete this form and comply with the investigative requirements for the position you currently occupy or have been
selected for could result in disciplinary action, up to and including removal. If the Department of the Treasury intends to
take any adverse action based in whole or in part on your credit report, you are entitled to certain protections set out in the
Fair Credit Reporting Act. These protections are provided below.

A Summary of Your Rights
Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) is designed to promote accuracy, fairness, and privacy of information in the
files of every “consumer reporting agency” (CRA). Most CRAs are credit bureaus that gather and sell information about
you -- such as if you pay your bills on time or have filed bankruptcy -- to creditors, employers, landlords, and other
businesses. You can find the complete text of the FCRA in 15 U.S.C. §§ 1681-1681u. The FCRA gives you specific
rights, as outlined below. You may have additional rights under state law. You may contact a state or local consumer
protection agency or a state attorney general to learn those rights.

• You must be told if information in your file has been used against you. Anyone who uses information from a

CRA to take action against you -- such as denying an application for credit, insurance, or employment -- must tell you,
and give you the name, address, and phone number of the CRA that provided the consumer report.

• You can find out what is in your file.

At your request, a CRA must give you the information in your file, and a list of
everyone who has requested it recently. There is no charge for the report if a person has taken action against you
because of information supplied by the CRA, if you request the report within 60 days of receiving notice of the action.
You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed
and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud.
Otherwise, a CRA may charge you up to eight dollars.

• You can dispute inaccurate information with the CRA.

If you tell a CRA that your file contains inaccurate
information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all
relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its
findings to the CRA. (The source also must advise national CRAs -- to which it has provided the data -- of any error.)
The CRA must give you a written report of the investigation and a copy of your report of the investigation results in
any change. If the CRA’s investigation does not resolve the dispute, you may add a brief statement to your file. The
CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement
is filed, you may ask that anyone who has recently received your report be notified of the change.

• Inaccurate information must be corrected or deleted.

A CRA must remove or correct inaccurate or unverified
information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove
accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in
any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies
its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the
item. The notice must include the name, address and phone number of the information source.

Form

13340 (1-2003)

Catalog Number 35089B

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

• You can dispute inaccurate items with the source of the information. If you tell anyone -- such as a creditor who
reports to a CRA -- that you dispute an item, they may not then report the information to a CRA without including a
notice of your dispute. In addition, once you have notified the source of the error in writing, it may not continue to
report the information if it is, in fact, an error.

• Outdated information may not be reported.

In most cases, a CRA may not report negative information that is more
than seven years old; ten years for bankruptcies.

• Access to your file is limited. A CRA may provide information about you only to people with a need recognized by
the FCRA - usually to consider an application with a creditor, insurer, employer, landlord, or other business.

• Your consent is required for reports that are provided to employers, or reports that contain medical

information. A CRA may not give out information about you to your employer, or prospective employer, without your
written consent. A CRA may not report medical information about you to creditors, insurers, or employers without your
permission.

• You may choose to exclude your name from CRA lists for unsolicited credit and insurance offers. Creditors

and insurers may use file information as the basis for sending you unsolicited offers of credit or insurance.
Such offers must include a toll-free phone number for you to call if you want your name and address removed from
future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form
provided for this purpose, you must be taken off the lists indefinitely.

• You may seek damages from violators. If a CRA, a user or (in some cases) a provider of CRA data, violates the
FCRA, you may sue them in state or federal court.

The FCRA gives several different federal agencies authority to enforce the FCRA:
For questions or concerns regarding:

Please contact:

National banks, federal branches/agencies of foreign banks
(word “National” or initials “N.A.” appear in or after banks
name)

Federal Trade Commission
Consumer Response Center - FCRA
Washington, DC 20580 * 202-326-3761
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 * 800-613-6743

Federal Reserve System member banks (except national
banks, and
federal branches/agencies of foreign banks)

Federal Reserve Board
Division of Consumer & Community Affairs
Washington, DC 20551 * 202-452-3693

Savings associations and federally chartered savings banks
(word “Federal” or initials “F.S.B.” appear in federal
institutions name)

Office of Thrift Supervision
Consumer Programs
Washington, DC 20552 * 800-842-6929

Federal credit unions (words “Federal Credit Union” appear
in institutions name)

National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 * 703-518-6360

State-chartered banks that are not members of the Federal
Reserve System

Federal Deposit Insurance Corporation
Division of Compliance & Consumer Affairs
Washington, DC 20429 * 800-934-FDIC

Air, surface, or rail common carriers regulated by former
Civil Aeronautics Board or Interstate Commerce
Commission

Department of Transportation
Office of Financial Management
Washington, DC 20590 * 202-366-1306

Activities subject to the Packers and Stockyards Act, 1921

Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250 * 202-720-7051

CRAs, creditors and others not listed below

Form

13340 (1-2003)

Catalog Number 35089B

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service

United States Department of the Treasury
Disclosure and Authorization Pertaining to Consumer Reports
Pursuant to the Fair Credit Reporting Act
This is a release for the Department of the Treasury to obtain one or more consumer/credit reports about you for an
investigation in connection with your application for employment or in the course of your employment with the Department
of the Treasury, including your employment as an IRS contractor. One or more reports about you may be obtained for
employment purposes, including evaluating your suitability for employment, promotion or reassignment which results in a
change to your position risk level, or access to classified information.

(This page must be returned with your investigative paperwork)

I,
hereby
authorize the Department of the Treasury to obtain such report(s) from any consumer/credit reporting agency for
employment purposes. This authorization is valid for 5 years from the signed date, or upon the termination of my
employment with the Internal Revenue Service/Department of Treasury, or until the IRS has completed the investigation,
whichever is sooner. If I apply for another position that requires a credit inquiry, I understand that I will be required to
complete a new authorization.

Signature

Date

Privacy Act
This form is in compliance with the Privacy Act of 1974. Our authorized right to ask for this information is 5 U.S.C. 301 and Executive Order 10450,
which established the criteria for sensitive Government positions. The information you supply by signing this release of information form will be used
principally to aid in the completion of an investigation to determine your suitability for employment in the Federal service or for other employment
purposes. Such purposes include, but are not limited to, a security clearance, evaluation of qualification, suitability, loyalty to the United States, and
eligibility for access to government facilities, information, or information technology systems. The information obtained may be re-disclosed to other
Federal agencies for the above purposes and to the extent that is authorized by law.
Your signature on this release is voluntary; however, your failure to complete this form may mean that the required information cannot be obtained to
complete your investigation. This may affect your placement or security clearance prospects.
If the Department of the Treasury intends to take any adverse action based in whole or in part on your credit report, you are entitled to certain
protections set out in the Fair Credit Reporting Act, 15 U.S.C. 1681b. These protections are attached for your information.

Form

13340 (1-2003)

Catalog Number 35089B

publish.no.irs.gov

Department of the Treasury - Internal Revenue Service