**Consent for Access to Records**

+-----------------------------------------------------+----------------+
| **PART I: AUTHORIZATION FOR RELEASE OF              |                |
| INFORMATION**                                       |                |
|                                                     |                |
| ***(to be completed by the individual)***           |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| I authorize any investigative agency of the         |                |
| Executive Branch of the United States Government to |                |
| request, pursuant to Section 1.2 (e), Executive     |                |
| Order (E.O.) 12968, Access to Classified            |                |
| Information, from any financial agency, financial   |                |
| institution, or holding company, or any consumer    |                |
| reporting agency, such financial records or other   |                |
| financial information, and consumer reports         |                |
| pertaining to me, as may be necessary in order to   |                |
| conduct any authorized law enforcement or           |                |
| counterintelligence investigation, or to determine  |                |
| my eligibility, or continued eligibility, for       |                |
| access to classified information. I hereby give the |                |
| same authorization with respect to any records      |                |
| maintained by any commercial entity within the      |                |
| United States pertaining to travel by me outside    |                |
| the United States.                                  |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| I understand that this release will not be used     |                |
| unless the required conditions stipulated in The    |                |
| Counterintelligence and Security Enhancement Act of |                |
| 1994 (50 U.S.C. §436\[a\]\[2\]) and Section 1.2     |                |
| (e)(2) E.O. 12968 have been met and the             |                |
| certification attesting to that fact appearing on   |                |
| the reverse of this consent form has been signed by |                |
| an authorized United States Government official.    |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| I direct each entity to which this request is       |                |
| presented to release the aforementioned records and |                |
| information, pursuant to 50 U.S.C. §436, upon the   |                |
| request of the authorized recipient as described    |                |
| above, regardless of any agreement or direction I   |                |
| may have previously made. I also understand that,   |                |
| under 50 U.S.C. §436(b), the fact that a request    |                |
| for records pertaining to me has been made will not |                |
| be disclosed to me by any such entity regardless of |                |
| any agreement or direction I may have made, or will |                |
| make.                                               |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| I have been advised the original of this            |                |
| authorization will be placed on file with the       |                |
| sponsoring Federal agency. This authorization       |                |
| expires three years after my current authorized     |                |
| access to classified information has terminated.    |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| Name (Last, First, MI)                              | SSN            |
+-----------------------------------------------------+----------------+
| Signature                                           | Date of Birth  |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| **PRIVACY ACT STATEMENT**                           |                |
|                                                     |                |
| **FOR PART I**                                      |                |
+-----------------------------------------------------+----------------+
| **AUTHORITY:** Collection of the information        |                |
| requested by this form is authorized under: 50      |                |
| U.S.C. §436, Counterintelligence and Security       |                |
| Enhancement Act of 1994, and E. O. 12968, Access to |                |
| Classified Information.                             |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| **PRINCIPAL PURPOSE:** The information supplied on  |                |
| this release will be used pursuant to 50 U.S.C.     |                |
| §436 to obtain such financial records, other        |                |
| financial information, consumer credit reports and  |                |
| records, and foreign travel information as may be   |                |
| necessary to conduct any authorized law enforcement |                |
| and/or counterintelligence investigation or to      |                |
| determine your eligibility or continued eligibility |                |
| for access to classified information as specified   |                |
| in Section 1.2(e)(2) of E. O. 12968.                |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| **ROUTINE USES:** Information reported on this      |                |
| release may be provided to financial agencies,      |                |
| financial institutions, holding companies, consumer |                |
| reporting agencies, and other commercial entities   |                |
| holding financial, consumer credit, or foreign      |                |
| travel records pertaining to you. It may also be    |                |
| provided to a congressional office in response to   |                |
| an inquiry made at your request; to the General     |                |
| Services Administration and National Archives and   |                |
| Records Administration for records management       |                |
| purposes; and to any agency of the United States    |                |
| conducting an authorized law enforcement            |                |
| investigation, counterintelligence inquiry, or      |                |
| security determination where the requirements of 50 |                |
| U.S.C. §436(a)(2)(B) are satisfied.                 |                |
+-----------------------------------------------------+----------------+
|                                                     |                |
+-----------------------------------------------------+----------------+
| **DISCLOSURE:** Participation is voluntary;         |                |
| however, under Executive Order 12968, failure to    |                |
| furnish the requested information will result in    |                |
| you not being eligible for new, or continued,       |                |
| access to classified information.                   |                |
+-----------------------------------------------------+----------------+

**Standard Form 713 FRONT (5-02)**

  --------------------------------------------------- -------------------
  Name (Last, First, MI                               SSN

  --------------------------------------------------- -------------------

+-----------------------------------+-----------------+----------------+
| # PART II: CERTIFICATION          |                 |                |
|                                   |                 |                |
| ***(to be completed by the        |                 |                |
| certifying official)***           |                 |                |
+-----------------------------------+-----------------+----------------+
| I HAVE REVIEWED THE FACTS OF THIS |                 |                |
| CASE AND CERTIFY:                 |                 |                |
+-----------------------------------+-----------------+----------------+
| 1\) The person to whom the signed |                 |                |
| authorization on the reverse of   |                 |                |
| this page applies is, or was, a   |                 |                |
| government employee as defined by |                 |                |
| 50 U.S.C. 436 et seq. who has     |                 |                |
| been required by the President in |                 |                |
| Executive Order 12968 to provide  |                 |                |
| the consent on the reverse of     |                 |                |
| this page as a condition of       |                 |                |
| access to classified information. |                 |                |
| The definition of employee in     |                 |                |
| that statute includes any person  |                 |                |
| who receives a salary or          |                 |                |
| compensation of any kind from the |                 |                |
| United States Government, is a    |                 |                |
| contractor of the United States   |                 |                |
| Government or an employee         |                 |                |
| thereof, is an unpaid consultant  |                 |                |
| of the United States Government,  |                 |                |
| or otherwise acts for or on       |                 |                |
| behalf of the United States       |                 |                |
| Government.                       |                 |                |
+-----------------------------------+-----------------+----------------+
| 2\) This request for information  |                 |                |
| and/or records is being made      |                 |                |
| pursuant to an authorized inquiry |                 |                |
| or investigation as specified in  |                 |                |
| Section 1.2(e)(2) of E. O. 12968, |                 |                |
| and is authorized under 50 U.S.C. |                 |                |
| §436(a)(2).                       |                 |                |
+-----------------------------------+-----------------+----------------+
| 3\) The employee, by his/her      |                 |                |
| signature on the "Authorization   |                 |                |
| for Release of Information" on    |                 |                |
| the reverse of this               |                 |                |
| certification, has previously     |                 |                |
| agreed to make available the      |                 |                |
| records or information requested  |                 |                |
| by this certification.            |                 |                |
+-----------------------------------+-----------------+----------------+
| Name of Certifying Official       | Title           |                |
+-----------------------------------+-----------------+----------------+
| Signature                         |                 | Date           |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| **PART III: STATEMENT OF RECORDS  |                 |                |
| REQUESTED**                       |                 |                |
|                                   |                 |                |
| ***(to be completed by the        |                 |                |
| investigative entity for each     |                 |                |
| specific request)***              |                 |                |
+-----------------------------------+-----------------+----------------+
| This request is directed          |                 |                |
| to\_                              |                 |                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_, |                 |                |
| covering the period               |                 |                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_ to     |                 |                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_,   |                 |                |
| for the following records:        |                 |                |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| A from financial institutions or  |                 |                |
| holding companies as defined in   |                 |                |
| 31 USC sec 5312 (a) or 12 USC     |                 |                |
| Sec. 3401 (6), respectively:      |                 |                |
+-----------------------------------+-----------------+----------------+
| 1\) Deposits, withdrawals, and    |                 |                |
| account balances                  |                 |                |
+-----------------------------------+-----------------+----------------+
| 2\) Copies of checks and other    |                 |                |
| negotiable instruments            |                 |                |
+-----------------------------------+-----------------+----------------+
| 3\) Funds transfers to or from    |                 |                |
| financial institutions outside    |                 |                |
| the United States                 |                 |                |
+-----------------------------------+-----------------+----------------+
| 4\) Other, as specified:          |                 |                |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| B from investment institutions as |                 |                |
| defined in 31 USC sec 5312 (a):   |                 |                |
+-----------------------------------+-----------------+----------------+
| 1\) Purchases of stocks, bonds,   |                 |                |
| or other securities with an       |                 |                |
| aggregate value greater than      |                 |                |
| \$\_\_\_\_\_\_\_\_\_              |                 |                |
+-----------------------------------+-----------------+----------------+
| 2\) Other, as specified:          |                 |                |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| C from credit reporting           |                 |                |
| institutions as defined in 15 USC |                 |                |
| 1681 et seq:                      |                 |                |
+-----------------------------------+-----------------+----------------+
| 1\) Credit records                |                 |                |
+-----------------------------------+-----------------+----------------+
| 2\) The identities of financial   |                 |                |
| institutions where the employee   |                 |                |
| maintains accounts                |                 |                |
+-----------------------------------+-----------------+----------------+
| 3\) Copies of correspondence      |                 |                |
| relating to creditworthiness      |                 |                |
+-----------------------------------+-----------------+----------------+
| 4\) Other, as specified:          |                 |                |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| D from holders of travel records  |                 |                |
| as defined in 50 USC 436 (a) (1): |                 |                |
+-----------------------------------+-----------------+----------------+
| 1\) Records of trips to and/or    |                 |                |
| from locations outside the United |                 |                |
| States                            |                 |                |
+-----------------------------------+-----------------+----------------+
| 2\) Other, as specified:          |                 |                |
+-----------------------------------+-----------------+----------------+
|                                   |                 |                |
+-----------------------------------+-----------------+----------------+
| **WARNING:** No government or     |                 |                |
| private entity, or officer,       |                 |                |
| employee, or agency of such       |                 |                |
| entity, may disclose to any       |                 |                |
| person, other than to those       |                 |                |
| officers, employees, or agents of |                 |                |
| such entity necessary to satisfy  |                 |                |
| a request made under this         |                 |                |
| section, that such agency has     |                 |                |
| received or satisfied a request   |                 |                |
| made by an authorized             |                 |                |
| investigative agency under this   |                 |                |
| section. An entity receiving a    |                 |                |
| request under this provision of   |                 |                |
| law must make the requested       |                 |                |
| information or records available  |                 |                |
| within 30 days for inspection or  |                 |                |
| copying as may be appropriate, by |                 |                |
| the agency requesting the         |                 |                |
| information (50 U.S.C. §436\[b\]  |                 |                |
| and \[c\]).                       |                 |                |
+-----------------------------------+-----------------+----------------+

**Standard Form 713 BACK (5-02)**