Posted by jlissem on 2/11/07 7:55pm
Msg #175280
LexisNexis request form
LEXISNEXIS® RISK & INFORMATION ANALYTICS GROUP
CONSUMER DISCLOSURE REQUEST FORM
If you wish to obtain a personal information disclosure report, you may complete, execute and submit this written disclosure request form along with a copy of two forms of identification at least one of which must be issued by a governmental entity (such as a drivers license, Social Security ID card, passport or military ID).
1) Identifying Information:
Please print clearly. Reference #:
Name: Other Names:
Address:
City: State: Zip:
Social Security Number: Date of Birth:
Driver’s License Number: Telephone Number(s):
Employer:
2) Identifying Documentation:
Forms of Identity Verification Submitted:
0Driver’s License 0Passport
0Social Security ID Card 0Military ID
0Other:
3) Authorization to release requested information:
I expressly request the release of all information in LexisNexis® Risk & Information Analytics Group files associated with me and further certify that all representations and information submitted as part of this requested are true and correct and that this request is not made to either initiate or perpetuate any fraudulent or otherwise illegal activity.
Signature: Date:
4) Return this Disclosure Request Form along with identifying documentation to:
LexisNexis® Risk & Information Analytics Group
Attn: Consumer Inquiry Department
P.O. Box 812289
Boca Raton, FL 33481
|
