ATTACHMENT H-4 - Authorization for Release of Credit Information.pdf

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U.S. Securities and Exchange Commission

Personnel Security Operations Branch

Authorization for Release of Credit Information

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 fo r Fede ral em ployment, (2) c learance t o p erform cont ractual se rvice f or t he Fede ral g overnment, and /or (3) eligibility for a sensitive position or access to classified information.

Authorization I author ize the investigative agency, any investigator, or oth er duly acc redited r epresentative of the US Securities and Exchange Com mission (SEC) conducting my bac kground i nvestigation t o o btain suc h rep orts f rom any consum er 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 Employment 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.

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)

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.

v.1 09/2012

ATTACHMENT H-4

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Authorization for Release of Credit Information

Privacy Act Statement The SEC is authorized to ask for this information under 5 CFR § 731 and 736, Executive Order 13467, 15 U.S. C. § 1681, et seq. and Executive Order 12968. The principal purpose of collecting this information is to assist SEC personnel in making an informed decision regarding suitability for a security clearance and to determine fitness for federal employment. Disclosure of your personal information is voluntary.

However, failure to provide the requested information may result in an adverse suitability determination.

In addition to the disclosures generally permitted under 5 U.S.C. § 552a(b) of the Privacy Act, the information contained herein may specifically be disclosed: (1) to a Federal, State, or local law enforcement agency if the disclosing agency becomes aware of a violation or potential violation of law or regulation; (2) to a court or party in a court or Federal administrative proceeding if the Government is a party or in order to comply with a judge-issued subpoena; (3) To a Federal, State, or local agency, in response to its requests, in connection with the hiring or retention of an employee, the issuance of a security clearance, or the conduct of a security or background investigation of an individual, to the extent that the information is relevant and necessary to the requesting agency; (4) to the National Archives and Records Administration or the General Services Administration in records management inspections; (5) To the Office of Inspector General for investigating allegations of fraud or misconduct; (6) to a Member of Congress or a congressional office in response to an inquiry made on behalf of an individual who is the subject of the record; and (7) to SEC contractors or their authorized employees, and other Federal agencies, as necessary, for the purpose of assisting the SEC in the efficient administration of its programs. These contractors will be required to maintain Privacy Act safeguards with respect to such records. Disclosures may also be made in accordance with the Office of Personnel Management published system of records notice. (See OPM/Central-9).

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