(This form letter requests the disclosure of all information in a Credit Bureau report to you or your personal representative.)
Pursuant to the Fair Credit Collection Act and other applicable laws and regulations, I request full disclosure of the nature and substance of all information (except medical) on me in your files, including the sources of the information (except investigative sources) and a listing of the recipients of any reports you furnished about me within the last six months (or the last two years if furnished for employment purposes).
This request is made because of credit, insurance, employment denied or adversely modified to me within the last 30 days by [NAME] DEPARTMENT STORE. This report is required by law to be at no charge.
LENGTH OF TIME AT PRESENT ADDRESS:
DATE OF BIRTH:
SOCIAL SECURITY NUMBER:
I understand the credit bureau will inform me in advance of any charges resulting from this interview for which I am properly responsible to pay.
I certify under the penalties of perjury and the civil penalty described that I am the person named above and I understand that federal law provides that a person who obtains information from a consumer reporting agency under false pretenses shall be fined not more than $------ or imprisoned not more than one year, or both.
I authorize the bureau named above to review my credit record with me in the presence of ____________________, who has furnished reasonable identification to the credit bureau.
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