1093 Authorization for Release of Credit Information

Authorization for Release of Credit Information

OMB Control Number: XXXX-XXXX

National Credit Union Administration
Office of Continuity and Security Management

Name (Legal Family)

Applicant Information

First (Legal Given)

Middle (or NMN if none)

Home Street Address (P.O. Box not accepted)

City

Other Names Used

State

Suffix

Zip Code

AUTHORIZATION

Purpose
Information provided by the signee will be furnished to the consumer reporting agency in order to obtain
information in connection with a background investigation pursuant to the Fair Credit Reporting Act (15 U.S.C.
§1681) to determine (1) suitability for Federal employment, (2) fitness to perform contractual service for the
Federal government, and/or (3) eligibility for a sensitive position or access to classified information.
Authorization
I hereby authorize the investigative agency, any investigator, special agent, or other duly accredited representative
of the National Credit Union Administration (NCUA) conducting my background investigation to obtain such reports
from any consumer reporting agency for employment purposes described above.
In obtaining this information, the NCUA is in compliance with all relevant provisions of the Fair Credit Reporting Act
(15 U.S.C. §1681).
I understand, that the NCUA will not take adverse action against me, based in whole or in part upon the credit
report, without first providing access to a copy of the credit report or a written description of my rights as described
in 15 U.S.C. §1681 and amendments or use any information from the consumer report in violation of any
applicable Federal or state Equal Employment Opportunity (EEO) law or regulation.
Copies of this authorization that show my signature are as valid as the original release. This authorization is valid
for five (5) years from the date signed or upon the termination of my affiliation with the Federal government,
whichever is sooner. Photocopies of this authorization with my signature are valid.

___________________________________________
Signature
Si

____________________________
Date Signed (mm/dd/yyyy)

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NCUA 1093

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INSTRUCTIONS
Use: This form, in its entirety, must be submitted for any applicant requiring access to NCUA information,
systems, or facilities.
Submission: A typed document is preferred to avoid delays and incorrect information. The applicant's full legal
name is required. All documentation must be submitted by the OHR representative or COR to Personnel Security
at [email protected].
Privacy Act
AUTHORITY: 5 CFR § 731 and 736; Executive Order 13467; Executive Order 12968/SEAD 4. Disclosure of the
requested information is not mandatory.
PURPOSE: To assist NCUA personnel in making an informed decision regarding suitability for federal
employment, fitness for contract employment, and/or granting of a security clearance.
ROUTINE USE(S): In addition to the disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act,
the information contained herein may specifically be used to document the outcome of adjudicative determination
for the issuance of the HSPD-12 PIV card or the local agency access badge, and to document the outcome of
adjudicative determinations for suitability, fitness, and/or national security clearances. Contact information is used
for communication and authentication purposes. A complete list of Routine Uses is available at NCUA-1, Personnel
Access and Security System (81 FR 12748).
EFFECTS OF NOT PROVIDING INFORMATION: The requested information is needed to process your claim for
employment and/or access. Disclosure of your personal information is voluntary. However, failure to provide the
requested information may result in ineligibility to gain or retain federal or contractor employment with the NCUA.
SORN: NCUA-1, Personnel Access and Security System (81 FR 12748), Office of Personnel Management
OPM/Central-9.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of
Management and Budget (OMB) control number. The OMB control number for this collection is XXXX-XXXX. We
estimate that it will take 10 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate, including suggestions for reducing this burden, or any other aspects of this
collection of information to: NCUA, Office of Continuity and Security Management,1775 Duke Street, Alexandria,
VA 22314-3428.

NCUA 1093