456. K: Post-Notice Following Court-Ordered—Form DOJ-471

RFPA

Form DOJ-471 -- Post-Notice Following Court-Ordered

(Name of Customer)

Records or information concerning your transactions which are held by the financial institution named in the attached process or request were supplied to or requested by the Government authority named in the process or request on _______________ ____ , 19 ___ .

(Date)

Notification was withheld pursuant to a determination by the United States District Court for the _______________ District of __________________ under the Right To Financial Privacy Act of 1978, 12 U.S.C. Secs. 3401-3422, that such notice might: _____________________________________________

___________________________________________________________

The purpose of the investigation or official proceeding was:

_________________________________________________________ .

____________ ____ , 19 ___

(Date) ____________________________

(Name and Title of Official)

____________________________

(Telephone)

____________________________

(Government Agency)

____________________________

(Address)

Attachment

Sec. 1109(b)(3) of the Right To Financial

FORM DOJ-47l

Privacy Act, 12 U.S.C. Sec. 3409(b)(3)