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460

O: Formal Written Request for Account Information and Certificate of Compliance With the—Form DOJ-475

RFPA

Form DOJ-475--Formal Written Request for Account Information and Certificate of Compliance With the

UNITED STATES DEPARTMENT OF JUSTICE

Washington, D.C. 20530

FORMAL WRITTEN REQUEST FOR ACCOUNT INFORMATION

AND

CERTIFICATE OF COMPLIANCE WITH

THE RIGHT TO FINANCIAL PRIVACY ACT

TO: ____________________________________________

(Name and Address of Financial Institution)

FROM: _____________________________________________

(Name and Address of Government Agency)

In connection with a legitimate law enforcement inquiry and pursuant to Section 1113(g) of the Right To Financial Privacy Act of 1978, 12 U.S.C. Section 3413(g), you are requested to provide the following account information:

I hereby certify, pursuant to Section 1103(b), the Right To Financial Privacy Act of 1978, 12 U.S.C. Section 3403(b), that the provisions of the Act have been complied with as to this request for account information and that 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 this account information.

______________________________

(Name and Title of Official)

______________________________

(Signature)

___________ ___ l9 __

(Date)

__________________________

(Government Agency)

Remarks:

Sec. 1113(g) of the Right To Financial

FORM DOJ-475

Privacy Act, l2 U.S.C. Sec. 3413(g)