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446

B: Customer Consent and Authorization for Access to Financial Records—Form DOJ-462

RFPA

Form DOJ-462 -- Customer Consent and Authorization for Access to Financial Records

UNITED STATES DEPARTMENT OF JUSTICE

Washington, D.C. 20530

CUSTOMER CONSENT AND AUTHORI2ATION

FOR ACCESS TO FINANCIAL RECORDS

I, __________________________________________ , having read (Name of Customer)

the explanation of my rights which is attached to this form, hereby authorize the _______________________________________

(Name and Address of Financial Institution)

to disclose these financial records: to _____________________, ___________________________ ,

(Names of Government Authorities Allowed Access)

___________________________ , for the following purpose(s):__________________________________________________________________ _ _____________________________________________________________________________ _ ______________________________________.

I understand that this authorization may be revoked by me in writing at any time before my records, as described above, are disclosed, and that this authorization is valid for no more than three months from the date of my signature.

______________ ___ , 19__ ____________________________

(Date) (Signature of Customer)

_______________________________

_______________________________

(Address of Customer)

Sec. 1104(a) of the Right To Financial

FORM DOJ-462

Privacy Act, 12 U.S.C. Sec. 3404(a)