ATCH-5_50310222R0007-Credit Release v 1 09 2012.pdf

U.S. Securities and Exchange Commission

Personnel Security Operations Branch Authorization for Release of Credit Information v.1 09/2012

Purpose Information provided by the signee will be furnished to the consumer reporting agency in order to obtain information in connection with a background investigation pursuant to the Fair Credit Reporting Act (15 U.S.C. §1681) to determine (1) fitness for Federal employment, (2) clearance to perform contractual service for the Federal government, and/or (3) eligibility for a sensitive position or access to classified information.

Authorization I authorize the investigative agency, any investigator, or other duly accredited representative of the US Securities and Exchange Commission (SEC) conducting my background investigation to obtain such reports from any consumer reporting agency for employment purposes described above.

In obtaining this information, the SEC is in compliance with all relevant provisions of the Fair Credit Reporting Act (15 U.S.C. §1681).

I understand that the SEC will not take adverse action against me, based in whole or in part upon the credit report, without first providing access to a copy of the credit report or a written description of my rights as described in 15 U.S.C. §1681 and amendments or use any information from the consumer report in violation of any applicable Federal or state Equal Employee Opportunity (EEO) law or regulation.

Copies of this authorization that show my signature are as valid as the original release. This authorization is valid for five

(5) years from the date signed or upon the termination of my affiliation with the Federal government, whichever is sooner.

Note: If you have a security freeze on your consumer or credit report file, then the SEC and its designated parties may not be able to complete your investigation, which can adversely affect your eligibility for employment or clearance to perform contractual services. To avoid such delays, you should request that the consumer reporting agencies lift the freeze in these instances.

1. Name (Last/Family) 2. First (Given) 3. Middle (or NMN) 4. Other Names Used 5. Suffix

6. Home Street Address

7. City 8. State 9. Zip Code 10. Phone Number

Signature (full name in ink) Date Signed (mm/dd/yyyy)