Fair Credit Reporting Act of 1970, as amended

**PLEASE TAKE NOTICE** THAT ONE OR MORE CONSUMER CREDIT REPORTS MAY BE
OBTAINED FOR EMPLOYMENT PURPOSES PURSUANT TO THE FAIR CREDIT REPORTING
ACT, AS AMENDED, 15 U.S.C. 1681, *ET, SEQ*. SHOULD A DECISION TO TAKE
ANY ADVERSE ACTION AGAINST YOU BE MADE, BASED EITHER IN WHOLE OR IN PART
ON THE CONSUMER CREDIT REPORT, THE CONSUMER REPORTING AGENCY THAT
PROVIDED THE REPORT PLAYED NO ROLE IN THE AGENCY'S DECISION TO TAKE SUCH
ADVERSE ACTION.

Information provided by you on this form will be furnished to the
consumer reporting agency in order to obtain information in connection
with an investigation to determine your (1) fitness for Federal
employment, (2) clearance to perform contractual service for the Federal
Government, and/or (3) security clearance or access. The information
obtained may be redisclosed to other Federal agencies for the above
purposes and in fulfillment of official responsibilities to the extent
that such disclosure is permitted by law.

This is to advise you that the Agency will not take adverse action
against you, based in whole or in part upon the credit report, without
first providing you with a copy of the report. The Agency will not use
any information from the consumer report in violation of any applicable
equal employment opportunity law or regulation.

I hereby acknowledge that I have received a written description of my
rights as described by the Federal Trade Commission under **Section
1681g(c)(3) of Title 15;** and authorize the Social Security
Administration to obtain such report(s) from any consumer/credit
reporting agency for employment purposes.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Print Name) SSN

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature) Date

Your Social Security Number is needed to keep records accurate, because
other people may have the same name. Executive Order 9397 also asks
Federal agencies to use this number to help identify individuals in
agency records.

**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, 15
U.S.C. 1681-1681u, at the Federal Trade Commission's web site
([http://www.ftc.gov](http://www.ftc.gov/) ). 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
    the 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 if 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.

2

-   **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've 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 from
    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       | **PLEASE CONTACT:**               |
| REGARDING:**                      |                                   |
+-----------------------------------+-----------------------------------+
| CRAs, creditors and others not    | Federal Trade Commission          |
| listed                            |                                   |
|                                   | Consumer Response Center -- FCRA  |
|                                   |                                   |
|                                   | Washington, D.C. 20580            |
|                                   |                                   |
|                                   | 202-326-3761                      |
+-----------------------------------+-----------------------------------+
| National Banks, federal           | Office of the Comptroller of the  |
| branches/agencies of foreign      | Currency Compliance Management,   |
| banks (word "National" or         | Mail Stop 6-6                     |
| initials "N.A." appear in or      |                                   |
| after bank's name)                | Washington, D.C. 20219            |
|                                   |                                   |
|                                   | 800-613-6743                      |
+-----------------------------------+-----------------------------------+

3

+-----------------------------------+-----------------------------------+
| Federal Reserve System members    | # Federal Reserve Board           |
| banks (except national banks, and |                                   |
| federal branches/ agencies of     | Division of Consumer & Community  |
| foreign banks)                    | Affairs                           |
|                                   |                                   |
|                                   | Washington, D.C. 20551            |
|                                   |                                   |
|                                   | 202-452-3693                      |
+-----------------------------------+-----------------------------------+
| Savings associations and          | Office of Thrift Supervision      |
| federally chartered savings banks |                                   |
| (word "Federal" or initials       | Consumer Programs                 |
| "F.S.B." appear in federal        |                                   |
| institution's name)               | Washington, D.C. 20552            |
|                                   |                                   |
|                                   | 800-842-6929                      |
+-----------------------------------+-----------------------------------+
| Federal credit unions (word       | National Credit Union             |
| "Federal credit union" appear in  | Administration                    |
| institution's name)               |                                   |
|                                   | 1775 Duke Street                  |
|                                   |                                   |
|                                   | Alexandria, VA 22314              |
|                                   |                                   |
|                                   | 703-518-6360                      |
+-----------------------------------+-----------------------------------+
| State-chartered banks that are    | Federal Deposit Insurance         |
| not members of the Federal        | Corporation                       |
| Reserve System                    |                                   |
|                                   | Division of Compliance & Consumer |
|                                   | Affairs                           |
|                                   |                                   |
|                                   | Washington, D.C. 20429            |
|                                   |                                   |
|                                   | 800-934-FDIC                      |
+-----------------------------------+-----------------------------------+
| Air, surface, or rail common      | Department of Transportation      |
| carriers regulated by former      |                                   |
| Civil Aeronautics Board or        | Office of Financial Management    |
| Interstate Commerce Commission    |                                   |
|                                   | Washington, D.C. 20590            |
|                                   |                                   |
|                                   | 202-366-1306                      |
+-----------------------------------+-----------------------------------+
| Activities subject to the Packers | Department of Agriculture         |
| and Stockyards Act, 1921          |                                   |
|                                   | Office of Deputy                  |
|                                   | Administrator-GIPSA Washington,   |
|                                   | D.C. 20450                        |
|                                   |                                   |
|                                   | 202-720-7051                      |
+-----------------------------------+-----------------------------------+