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452

G: Application of the United States Department of Justice for an Ex Parte Order Pursuant to Section 1109 of the Right to Financial Privacy Act of 1978—Form DOJ-467

RFPA

Form DOJ-467-- Application of the United States Department of Justice for an Ex Parte Order Pursuant to Section 1109 of the Right to Financial Privacy Act of 1978

IN THE UNITED STATES DISTRICT COURT

FOR THE _______________ DISTRICT OF ________________

_______________ DIVISION

In Re _____________

Misc. No.__________________

APPLICATION OF THE UNITED

STATES DEPARTMENT OF JUSTICE

FOR AN EX PARTE ORDER PURSUANT

TO SECTION 1109 OF THE RIGHT

TO FINANCIAL PRIVACY ACT OF 1978

The United States Department of Justice hereby applies to this Court, pursuant to Section 1109 of the Right to Financial Privacy Act of 1978, 12 U.S.C. Sec. 3409, for an order delaying for _____ days the customer notification required by Section ________ of the Act in connection with the ____________________________ that ______________________________

(Form of Process or Request) (Departmental Unit) has issued to obtain financial records pertaining to ____________________________ from ______________________________

(Customer) (Name or Financial Institution) and prohibiting ______________________________ , its officers,

(Name of Financial Institution) employees, or agents, from disclosing that such records have been released or that a request for such records has been made, on the grounds that, as shown by the attached affidavit:

  1. The investigation being conducted is within the lawful jurisdiction of the Government authority seeking the financial records;

  2. There is relevant to a legitimate law enforcement inquiry; and,

  3. There is reason to believe that the notice will result in: _____________________________________________

(See 12 U.S.C. Sec. 34O9(a)(3))

Respectfully submitted,

__________________________

Attachment

Sec. 1109 of the Right to Financial

FORM DOJ-467

Privacy Act, 12 U.S.C. Sec. 3409