APPENDIX M
SAMPLE FORM UNDER THE FCRA (REQUEST FOR CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT)

These forms are designed for the employer that intends to procure both a consumer report and an investigative consumer report about an applicant. Under the current interpretation of the law by the Federal Trade Commission ("FTC"), in this situation the full initial disclosures are required, even though a somewhat redundant disclosure would still need to be made at the time that an intent was formed to take adverse action based on the report.

These forms are for guideline purposes only. Contact counsel before use. In the event that the FTC changes its reading of the law, or if a statute is amended, of course, further revisions to these forms may be required.

[ ] Keep this applicant release in secure files separate from personnel records.

[EMPLOYER]

NOTICE TO APPLICANT REGARDING

CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT

AND CONSENT FORM

In connection with your application for employment with [EMPLOYER], you are required to consent, in writing, to the issuance to [EMPLOYER] of a Consumer Report and an Investigative Consumer Report about you.

Set forth below is important information about these two kinds of reports and your rights under the federal Fair Credit Reporting Act, 15 U.S.C. § 1681 et seq. Please read this information carefully. If you have any questions about these reports, please contact [EMPLOYER] Human Resources Department at _______________.

RELEASE AND AUTHORIZATION FOR CONSUMER REPORT AND INVESTIGATIVE CONSUMER REPORT

DISCLOSURE: A CONSUMER REPORT AND AN INVESTIGATIVE CONSUMER REPORT MAY BE PROCURED FOR EMPLOYMENT PURPOSES.

I voluntarily and knowingly authorize, for employment purposes only, for [EMPLOYER] to have [INSERT NAME OF CONSUMER REPORTING EMPLOYER], a Consumer Reporting Employer ("CRA"), obtain a Consumer Report and an Investigative Consumer Report on me. A Consumer Report as defined by the Fair Credit Reporting Act ("FCRA") is a written report prepared by a CRA that may be a summary of my credit standing, capacity, or worthiness, character, general reputation, personal characteristics or mode of living. An Investigative Consumer Report is a report prepared by a CRA that may contain information on my character, general reputation, personal characteristics, or mode of living obtained through personal interviews with my friends, neighbors or associates. I have received and reviewed a copy of the accompanying Notice of Consumer Report and Investigative Consumer Report and Summary of Rights under the FCRA.

SIGNATURE DATE
FULL NAME (type or print legibly)
STREET ADDRESS
CITY, STATE, ZIP
___________________________ SOCIAL SECURITY NUMBER
____________________________ DRIVER'S LICENSE NUMBER _________________ STATE OF ISSUE

THE SUMMARY OF RIGHTS AND CHART MUST BE IN 12 PT TYPE AND BOLD WHERE INDICATED

TO BE SENT TO EMPLOYEE OR APPLICANT:

(1) PRIOR TO TAKING ADVERSE EMPLOYMENT ACTION BASED ON A CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT. THIS DOCUMENT MUST BE 12 POINT TYPE AND BOLD WHERE INDICATED. THE DOCUMENT SHOULD ACCOMPANY A COPY OF THE CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT THAT MAY SERVE AS THE BASIS FOR ADVERSE EMPLOYMENT ACTION.

OR

A Consumer Report is a written report prepared by a consumer reporting ("CRA") that may be a summary of your credit standing, capacity, or worthiness, character, general reputation, personal characteristics or mode of living. An Investigative Consumer Report is a report prepared by a CRA that may contain information on your character, general reputation, personal characteristics, or mode of living obtained through personal interviews with your friends, neighbors or associates. The CRA that will be conducting this investigation is [INSERT NAME OF CRA]

Under the Fair Credit Reporting Act, you have the right to request additional information on the nature and scope of the Investigative Consumer Report of which you may be the subject. If you wish to exercise this right, please send a written request to [INSERT NAME AND ADDRESS OF PERSON AT EMPLOYER RESPONSIBLE FOR RESPONDING TO EMPLOYEE REQUESTS FOR ADDITIONAL INFORMATION UNDER THE FCRA].

A Summary of Your Rights

Under the Fair Credit Reporting Act

The federal Fair Credit Reporting Act (“FCRA”) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies.  There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records).  Here is a summary of your major rights under the FCRA.  For more information, including information about additional rights, go to www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.

· You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

·You can find out what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure”).  You will be required to provide proper identification, which may include your Social Security number.  In many cases, the disclosure will be free.  You are entitled to a free disclosure if:

·        a person has taken adverse action against you because of information in your credit report;

·        you are the victim of identity theft and place a fraud alert in your file;

·        your file contains inaccurate information as a result of fraud;

·        you are on public assistance;

·        you are unemployed but expect to apply for employment within 60 days.

· You have the right to ask for a credit score.  Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus.  You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it.  In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

· You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous.  See www.ftc.gov/credit for an explanation of disputes procedures.

·  Consumer reporting agencies must correct of delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days.  However, a consumer reporting agency may continue to report information it has verified as accurate.

· Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

· Access to your file is limited. A credit reporting agency may provide information about you only to people with a valid need – usually to consider an application with a creditor, insurer, employer, landlord, or other business.  The FCRA specifies those with a valid need for access.

· You Must give your consent for reports to be provided to employers.  A consumer reporting agency may not give out information about you to your employer, or potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry.  For more information, go to www.ftc.gov/credit.

· You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free number you can call if you choose to remove your name and address from the lists these offers are based on.  You may opt-out with the nationwide credit bureaus at 1-800-XXX-XXXX.

· You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

· Identity theft victims and active duty military personnel have additional rights. For more information, visit www.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws.  In some cases, you may have more rights under state law.  For more information, contact your state or local consumer protection agency or your state Attorney General.  Federal enforcers are:

TYPE OF BUSINESS	PLEASE CONTACT:
Consumer reporting agencies, creditors and others not listed below	Federal Trade Commission Consumer Response Center - FCRA Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word "National" or initials "N.A." appear in or after bank's name)	Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-6 Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)	Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693
Savings associations and federally chartered savings banks (word "Federal" or initials "F.S.B." appear in federal institution's name)	Office of Thrift Supervision Consumer Complaints Washington, DC 20552 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in institution's name)	National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal Reserve System	Federal Deposit Insurance Corporation Consumer Response Center 2345 Grand Avenue, Suite 100 Kansas City, Missouri 64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission	Department of Transportation Office of Financial Management Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921	Department of Agriculture Office of Deputy Administrator - GIPSA Washington, DC 20250 202-720-7051

[EMPLOYEE OR APPLICANT IS TO BE PROVIDED NOTICE OF THE FOLLOWING EITHER ORALLY, IN WRITING OR ELECTRONICALLY IF ANY ADVERSE EMPLOYMENT ACTION IS TAKEN BASED ON A CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT]

NOTICE TO EMPLOYEE OR APPLICANT OF ADVERSE ACTION TAKEN

BASED ON A CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT

This is to inform you that you were subject to adverse employment action based on a recent [SPECIFY WHETHER CONSUMER REPORT OR INVESTIGATIVE CONSUMER REPORT] which you were the subject of in conjunction with your application for employment. [DESCRIBE ADVERSE ACTION, I.E., DENIAL OF JOB]. The consumer reporting employer which conducted the report is [INSERT NAME OF EMPLOYER]. You have the right to contact the consumer reporting employer by writing to [INSERT ADDRESS] or by calling [INSERT TELEPHONE NUMBER OF EMPLOYER AND TOLL FREE NUMBER OF EMPLOYER IF EMPLOYER COMPILES AND MAINTAINS FILES ON CONSUMERS ON A NATIONWIDE BASIS]. The consumer reporting employer did not make the decision to take the adverse action and it is unable to provide you with the specific reasons why the adverse action was taken.

Although you have already been provided with a copy of the consumer report or investigative consumer report of which you were the subject, under the Fair Credit Reporting Act ("FCRA"), you have the right to obtain a free (and possibly updated) copy of the report. In order to obtain your free copy of the report, you must notify the consumer reporting employer within 60 days after you have received a copy of this notice. In addition, you have the right under the FCRA to dispute with the consumer reporting employer the accuracy or completeness of any information in the consumer report furnished by the employer.

SAMPLE EMPLOYER CERTIFICATION FORM TO CONSUMER REPORTING EMPLOYER

TO BE SENT TO CONSUMER REPORTING EMPLOYER WHEN REQUESTING CONSUMER REPORT OR INVESTIGATIVE REPORT

[EMPLOYER] does hereby certify the following:

When using the information from a consumer report or investigative consumer report for employment purposes, we will:

· make a clear and conspicuous disclosure to the employee or applicant ("consumer") in a separate document that a consumer report or investigative consumer report may be requested;

· obtain written permission from the consumer authorizing procurement of the consumer report or investigative consumer report before any reports are ordered;

· when an investigative consumer report is sought, we will disclose that an investigative consumer report including information as to the consumer's character, general reputation, personal characteristics and mode of living has been requested. This disclosure will be in writing and made not later than three days after the date on which the report was first requested. The disclosure will also include a statement informing the consumer of his or her right to request additional disclosures and will include a copy of the Summary of Rights of the Consumer;

· when a consumer makes a written request for additional disclosure of information about the investigative consumer report he or she may be the subject of within a reasonable time after receiving the initial disclosure, we will make a complete and accurate disclosure of the nature and scope of the investigation requested. This disclosure will be made in writing, mailed to the consumer not later than five days after the date on which the request for such disclosure was received from the consumer or such report was first requested, whichever is later;

· prior to taking any adverse employment action we will send the consumer a copy of the report which would serve as the basis for adverse employment action along with a copy of the "Summary of Consumer Rights Under the FCRA"; and

· information from any consumer report or investigative consumer report will not be used in violation of any applicable federal or state equal employment opportunity law or regulation and will only be used for employment purposes.

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NAME

___________________________________

SIGNATURE

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DATE