CONSUMER STATEMENT REQUEST
Please print legibly in blue or black ink.
SECTION A: Consumer Information
Full Name: First:
Middle:
Last:
(Check one if applicable):
Jr.
Sr.
Date of Birth:
Social Security or Individual Tax Identification Number:
(Include a copy of your SSN or ITIN card)
Full Current Address: (Information will be mailed to this address.)
Street Address:
Apt.#:
City:
State:
Zip:
Phone Numbers: Home (
)
Work (
)
Mobile (
)
(Area code) (Number)
(Area code) (Number)
(Area code) (Number)
SECTION B: STATEMENT
You may add a brief 100-word Consumer Statement to append to your file. Per the Fair Credit Reporting
Act, as a Consumer Reporting Agency, we must include a summary of your statement in future reports.
Please include case numbers and dates if applicable.
I affirm, under penalty of law, that to the best of my knowledge, the information provided above is true and correct.
Signature: ____________________________________________________________________________
Printed Name:
Date:
CsmrStmtRqstWeb frm 2005-06-20-01a OPSCR