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459

N: Certification for Transferring Records Obtained Pursuant to the Right to Financial Privacy Act of 1978—Form DOJ-474

RFPA.C. 20530

CERTIFICATION FOR TRANSFERRING RECORDS

OBTAINED PURSUANT TO THE RIGHT TO

FINANCIAL PRIVACY ACT OF 1978

TO: ________________________________________________________

(Name and Address of Receiving Agency)

FROM:_______________________________________________________

(Name and Address of Transferring Government Agency)

The records of the following customer of a financial institution are in our possession:

_____________________________________________________________

(Name of Customer)

_____________________________________________________________

(Address of Customer)

_____________________________________________________________

(Type of Records and Account Number)

_____________________________________________________________

(Name of Financial Institution)

Pursuant to Section 1112(a) of the Right To Financial Privacy Act of 1978, 12 U.S.C. Sec. 3412(a), the records described above are being transferred to you. I certify that there is reason to believe that the records being transferred are relevant to a legitimate law enforcement inquiry within the jurisdiction of your agency or department.

____________ ___ 19 ___ ____________________________

(Date) (Name of Official and Title)

_________________________ ____________________________

(Telephone) (Government Agency)

Copies to the Following Files:

Sec. 1112(a) of the Right to Financial

FORM DOJ-474

Privacy Act, l2 U.S.C. Sec. 3412(a)