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445

A: Certificate of Compliance with the Right to Financial Privacy Act of 1978—Form DOJ-461

RFPA

Form DOJ-461 -- Certificate of Compliance with the Right to Financial Privacy Act of 1978

UNITED STATES DEPARTMENT OF JUSTICE

Washington, D.C. 20530

CERTIFICATE OF COMPLIANCE

WITH THE RIGHT TO FINANCIAL PRIVACY ACT OF 1978

TO: _________________________________________________

_________________________________________________

(Name and Address of Financial Institution)

FROM: _________________________________________________

(Name of Government Agency)

I hereby certify that the applicable provisions of the Right To Financial Privacy Act of 1978, 12 U.S.C. Secs.3401-3422, have been complied with as to the __________________________________________________________

(Summons, Subpoena or Formal Written Request)

presented on ____________ _____ , 19 ___ for the following

(Date)

financial records of ____________________________________ :

_________________________________________________________

_________________________________________________________

____________ __, 19__ ___________________________

(Date) (Signature)

___________________________ ___________________________

(Name and Title of Official)

___________________________ ___________________________
(Address) (Government Agency)

___________________________

(Telephone)

Pursuant to the Right To Financial Privacy Act of 1978, good faith reliance upon this certificate relieves your institution and its employees and agents of any possible liability to the customer in connection with the disclosure of these financial records.

Sec. 1103(b) of the Right To Financial

FORM DOJ-461

Privacy Act, 12 U.S.C. Sec. 3403(b)