f1600-10 - Notice and Authorization Pertaining to Consumer Reports.pdf

Page 1 of 2FDIC 1600/10 (6-25)

Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING

TO CONSUMER REPORTS PURSUANT TO THE

FAIR CREDIT REPORTING ACT OF 1970,

15 U.S.C. § 1681, et seq.

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820; 15 U.S.C. § 1681; and Executive Order 9397 as amended. The FDIC will use this information to obtain one or more consumer reports as part of a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses described in the FDIC's System of Records Notice (SORN), Personnel Records (FDIC-015). A complete copy of this SORN is available for review at https://www.fdic.gov/about/system-records-notices. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

Page down to access form FDIC 1600/10 https://www.fdic.gov/about/system-records-notices mailto:Privacy@fdic.gov

Page 2 of 2FDIC 1600/10 (6-25)

Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING

TO CONSUMER REPORTS PURSUANT TO THE

FAIR CREDIT REPORTING ACT OF 1970,

15 U.S.C. § 1681, et seq.

INSTRUCTIONS: This form is to be completed by Applicants seeking employment or Contractor Personnel seeking positions. Item 4. (Applicant/Contractor Personnel Signature) will require an ink (wet) signature.

Executive Order 9397 (November 22, 1943) asks federal agencies to use Social Security Numbers (SSN) to help identify individuals in agency records. Your SSN is therefore needed to keep records accurate, because other people may have the same name. Providing your SSN is voluntary; however, failure to provide the requested information could result in the FDIC receiving an erroneous credit report.

Please take notice that one or more consumer reports may be obtained for employment purposes. Because a background investigation will be conducted as part of a determination of your fitness for employment, or for performance under a contract, you are also entitled to request additional disclosures concerning the nature and scope of the investigation.

By signing this form, you are giving consent to have your consumer reports furnished by consumer reporting agencies as part of an investigation to determine your (1) fitness for federal employment, (2) clearance to perform contractual service, and/or (3) security clearance or access. The information obtained may be re-disclosed to other federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.

This authorization is valid for one (1) year from the date signed or upon my separation of employment/services from the

FDIC.

SECTION I - APPLICANT/CONTRACTOR PERSONNEL INFORMATION

1. Name 2. Last 4-Digits of SSN

SECTION II - AUTHORIZATION AND SIGNATURE

I hereby authorize the FDIC to obtain such report(s) from any consumer-reporting agency for employment purposes.

3. Applicant/Contractor Personnel Signature (Sign in ink) 4. Date

FDIC 1600/10 (6-25)

FDIC 1600/10 (6-25)

FDIC 1600/10 (6-25)

FDIC 1600/10 (6-25)

Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING

TO CONSUMER REPORTS PURSUANT TO THE

FAIR CREDIT REPORTING ACT OF 1970,

15 U.S.C. § 1681, et seq.

Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING

TO CONSUMER REPORTS PURSUANT TO THE

FAIR CREDIT REPORTING ACT OF 1970,

15 U.S.C. § 1681, et seq.

PRIVACY ACT STATEMENT

PRIVACY ACT STATEMENT

The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820; 15 U.S.C. § 1681; and Executive Order 9397 as amended. The FDIC will use this information to obtain one or more consumer reports as part of a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses described in the FDIC's System of Records Notice (SORN), Personnel Records (FDIC-015). A complete copy of this SORN is available for review at https://www.fdic.gov/about/system-records-notices. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

Page down to access form FDIC 1600/10 The FDIC is authorized to request this information from you by 12 U.S.C. §§ 1819, 1820; 15 U.S.C. § 1681; and Executive Order 9397 as amended. The FDIC will use this information to obtain one or more consumer reports as part of a background investigation to determine whether you meet the required fitness and integrity standards for employment or performance under a contract with the FDIC. Furnishing the requested information is voluntary, but failure to provide the requested information in whole or in part may delay or prohibit any further consideration of you for employment or performance under a contract with the FDIC. The information you provide may be provided to appropriate Federal, state, local or foreign agencies and law enforcement authorities; to a court, administrative tribunal, or a party in litigation; and to contractors, agents and other third parties as authorized by law and in accordance with any of the other routine uses described in the FDIC's System of Records Notice (SORN), Personnel Records (FDIC-015). A complete copy of this SORN is available for review at https://www.fdic.gov/about/system-records-notices. If you have questions or concerns about the collection or use of the information, you may contact the FDIC's Chief Privacy Officer at Privacy@fdic.gov.

Page down to access form FDIC 1600/10 Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING

TO CONSUMER REPORTS PURSUANT TO THE

FAIR CREDIT REPORTING ACT OF 1970,

15 U.S.C. § 1681, et seq.

Federal Deposit Insurance Corporation

NOTICE AND AUTHORIZATION PERTAINING

TO CONSUMER REPORTS PURSUANT TO THE

FAIR CREDIT REPORTING ACT OF 1970,

15 U.S.C. § 1681, et seq.

INSTRUCTIONS: This form is to be completed by Applicants seeking employment or Contractor Personnel seeking positions. Item 4. (Applicant/Contractor Personnel Signature) will require an ink (wet) signature.

INSTRUCTIONS: This form is to be completed by Applicants seeking employment or Contractor Personnel seeking positions. Item 4. (Applicant/Contractor Personnel Signature) will require an ink (wet) signature.

Executive Order 9397 (November 22, 1943) asks federal agencies to use Social Security Numbers (SSN) to help identify individuals in agency records. Your SSN is therefore needed to keep records accurate, because other people may have the same name. Providing your SSN is voluntary; however, failure to provide the requested information could result in the FDIC receiving an erroneous credit report. Please take notice that one or more consumer reports may be obtained for employment purposes. Because a background investigation will be conducted as part of a determination of your fitness for employment, or for performance under a contract, you are also entitled to request additional disclosures concerning the nature and scope of the investigation. By signing this form, you are giving consent to have your consumer reports furnished by consumer reporting agencies as part of an investigation to determine your (1) fitness for federal employment, (2) clearance to perform contractual service, and/or (3) security clearance or access. The information obtained may be re-disclosed to other federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law. This authorization is valid for one (1) year from the date signed or upon my separation of employment/services from the FDIC.

Executive Order 9397 (November 22, 1943) asks federal agencies to use Social Security Numbers (SSN) to help identify individuals in agency records. Your SSN is therefore needed to keep records accurate, because other people may have the same name. Providing your SSN is voluntary; however, failure to provide the requested information could result in the FDIC receiving an erroneous credit report.

Please take notice that one or more consumer reports may be obtained for employment purposes. Because a background investigation will be conducted as part of a determination of your fitness for employment, or for performance under a contract, you are also entitled to request additional disclosures concerning the nature and scope of the investigation.

By signing this form, you are giving consent to have your consumer reports furnished by consumer reporting agencies as part of an investigation to determine your (1) fitness for federal employment, (2) clearance to perform contractual service, and/or (3) security clearance or access. The information obtained may be re-disclosed to other federal agencies for the above purposes and in fulfillment of official responsibilities to the extent that such disclosure is permitted by law.

This authorization is valid for one (1) year from the date signed or upon my separation of employment/services from the FDIC.

SECTION I - APPLICANT/CONTRACTOR PERSONNEL INFORMATION

SECTION 1 - APPLICANT/CONTRACTOR PERSONNEL INFORMATION

SECTION II - AUTHORIZATION AND SIGNATURE

SECTION 2 - AUTHORIZATION AND SIGNATURE

I hereby authorize the FDIC to obtain such report(s) from any consumer-reporting agency for employment purposes.

I hereby authorize the FDIC to obtain such report(s) from any consumer-reporting agency for employment purposes.

S. Todd Hamme For questions regarding this form, email Forms@fdic.gov.

FDIC

1600/10, NOTICE AND AUTHORIZATION PERTAINING TO CONSUMER REPORTS PURSUANT TO THE FAIR CREDIT REPORTING ACT OF 1970, 15 U.S.C. § 1681, et seq.

6-11-25 (AH)

10/31/16

DOA/SEPS