36C25520R0005-007.pdf

AUTHORIZATION FOR RELEASE OF INFORMATION

PROTECTED UNDER THE FAIR CREDIT REPORTING ACT (TITLE 15, SECTION 1681)

STATEMENT OF AUTHORIZATION AND CLARIFICATION OF PURPOSE

I Authorize the Department of Veterans Affairs Security Office to obtain Credit Reports from the Credit Bureau and other Consumer Reporting Agencies, Collection Agencies, and Retail Business Establishments which hold financial and credit information.

The Security Office will not take adverse action against the subject of investigation, based in whole or in part upon the results of the credit report. Should adverse action occur, the VA will provide a copy of the report and a written description of the subject's rights as described by the FTC under Section 1681g (c)(3) of Title

15. Any information from the consumer report, in violation of any applicable equal employment opportunity law or regulation, will not be used in the adjudication of the investigation.

I Authorize custodians of records and other sources of information pertaining to me to release such information upon the request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary.

I Understand that the information released by records custodians and sources of information is for official use by the Department of Veterans Affairs, Office of Security and Law Enforcement, only for the purposes of the adjudication and establishment of eligibility/security clearance.

Copies of this authorization that show my signature are as valid as the original release signed by me. This authorization is valid for (5) years from the date signed or upon the termination of my affiliation with the Department of Veterans Affairs, whichever is sooner.

SIGNATURE OF EMPLOYEE (Sign in ink) TYPE OR PRINT LEGIBLY FULL NAME DATE SIGNED

OTHER NAMES USED HOME TELEPHONE NUMBER (Include Area Code)

CURRENT ADDRESS (Include Street, City, State, and ZIP Code)

VA FORM

MAY 1998 0710

Attachment (5)

VA255-17-R-0753