Form 3170-XXXX FBI Name Check Form

OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX

FBI Name Check
Consumer Financial Protection Bureau
MEMORANDUM TO:

Personnel Security Program Manager

FROM:

Program Management Advisor

SUBJECT:

FBI Name Check Process Request Form

Please provide the requested information which is required for an FBI Name Check (Please print or type):
Name of Advisory Group to which you are applying to be a representative.

Name (Print last, first, middle initial)

Other Names Used and Dates

Present Employer

Present Occupation

Employer Address

Place of Birth (City, State)

Date of Birth

Country of Citizenship

Social Security Number
*Voluntary - See Privacy Act

Resident Address(es) for past 5 years (No., Street, City, State)

OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX
Other Identifying Information (Federal Employment, Arrest, Etc.)

For CFPB Program Management Use:

Badge Required:

Yes

No

Privacy Act Statement
The information that you provide will be used by the Consumer Financial Protection Bureau (CFPB) to determine
qualifications, suitability, and availability for service on advisory boards, bodies, panels, committees or other similar
groups. The information will be used to conduct background clearances and/or for annual reports on advisory
boards, bodies, panels, committees or other similar groups. The information will be used by and disclosed to
employees, contractors, agents, and others authorized by the CFPB to receive this information to assist in related
activities. The information may also be disclosed to:
(1) Appropriate agencies, entities, and persons when: (a) the CFPB suspects or has confirmed that the security or
confidentiality of information in the system of records has been compromised; (b) the CFPB has determined that, as
a result of the suspected or confirmed compromise, there is a risk of harm to economic or property interests, identity
theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained
by the CFPB or another agency or entity) that rely upon the compromised information; and (c) the disclosure made
to such agencies, entities, and persons is reasonably necessary to assist in connection with the CFPB’s efforts to
respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm;
(2) Another federal or state agency to (a) permit a decision as to access, amendment or correction of records to be made
in consultation with or by that agency, or (b) verify the identity of an individual or the accuracy of information
submitted by an individual who has requested access to or amendment or correction of records;
(3) To the Office of the President in response to an inquiry from that office made at the request of the subject of a record
or a third party on that person’s behalf;
(4) Congressional offices in response to an inquiry made at the request of the individual to whom the record pertains;
(5) Contractors, agents, or other authorized individuals performing work on a contract, service, cooperative agreement,
job, or other activity on behalf of the CFPB or Federal Government and who have a need to access the information
in the performance of their duties or activities;
(6) The U.S. Department of Justice (“DOJ”) for its use in providing legal advice to the CFPB or in representing the
CFPB in a proceeding before a court, adjudicative body, or other administrative body before which the CFPB is
authorized to appear, where the use of such information by the DOJ is deemed by the CFPB to be relevant and
necessary to the litigation, and such proceeding names as a party or interests:
(a) The CFPB;
(b) Any employee of the CFPB in his or her official capacity;
(c) Any employee of the CFPB in his or her individual capacity where DOJ has agreed to represent the employee; or
(d) The United States, where the CFPB determines that litigation is likely to affect the CFPB or any of its components;
(7) To the public in the form of names, affiliations, and other pertinent biographical information of board or committee
members; and
(8) Appropriate agencies, entities, and persons to the extent necessary to obtain information relevant to making a
determination of whether an individual is eligible to serve on a CFPB board or committee.
The collection of this information is authorized by Pub. L. No. 111-203, Title X, sections 1011, 1012, 1014, codified
at 12 U.S.C. §§ 5491, 5492, 5494. Providing your identifying information is voluntary, but not doing so may result
in non-selection of a prospective advisory board, body, panel, committee, or other similar group membership.
However, failure to provide your Social Security number may not be the reason for non-selection.

OMB Control #3170-XXXX
Expiration Date: XX/XX/XXXX
Paperwork Reduction Act
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 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 60 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 obligation to respond to this collection of information
is required for consideration on CFPB Advisory Board or Councils. Comments regarding this collection of
information, including the estimated response time, suggestions for improving the usefulness of the information, or
suggestions for reducing the burden to respond to this collection should be submitted to Bureau at the Consumer
Financial Protection Bureau (Attention: PRA Office), 1700 G Street NW, Washington, DC 20552, or by email to
[email protected].

I certify that the statements I have made on this form and all attached statements are true, complete, and correct to the
best of my knowledge.
Signature
Date (mm/dd/yyyy)