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 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 Department of Health
and Human Services, Office of Inspector General conducting my background investigation to obtain such reports from
any consumer reporting agency for employment purposes described above.
I understand that the DHHS OIG 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.
In obtaining this information, the DHHS OIG is in compliance with all relevant provisions of the Fair Credit Reporting
Act (15 U.S.C. §1681). 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. Social Security Number 7. Date of Birth 8. Phone Number
9. Home Street Address
10. City 11. State 12. Zip Code
Note: If you have a security freeze on your consumer or credit report file, then the DHHS OIG 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 or obtain one-time PINs.
The DHHS 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 HHS OIG personnel in making an informed decision regarding suitability or fitness for employment and/or
eligibility for a security clearance. Disclosure of your personal information is voluntary. However, failure to provide the requested information may result in an
unfavorable eligibility determination or adverse suitability/fitness determination. The information contained within may be disclosed as generally permitted under 5
U.S.C. § 552a(b) of the Privacy Act, as amended.
v.1 10/2014
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