Data Request For Usis Consumer Reporting Agency

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Dear USIS Consumer Reporting Agency:
Enclosed is a legible copy of my current driver’s license and social security card.
Pursuant to the enclosed Limited Power of Attorney and accompanying documentation I am
requesting a copy of any and all records stored in your databases including but not limited to the
employment index database, motor vehicle records, criminal records, workers compensation
reports, drug/alcohol records (including information in your controlled substance file), etc.
In addition, I am requesting a listing of any companies making inquiries into my records for the
last 2 years.
The following reason(s) qualify me to receive my record:
o I have been denied employment based on information contained in my records.
o I am entitled to one free copy of my records annually. I have not received my free
copy prior to this request.
o I believe there is fraudulent information contained in my records.
I hereby appoint as my designated Limited Power of Attorney. To communicate with
the USIS dba DAC Services and it’s employees to request Consumer Report(s), submit dispute(s)
related to the accuracy and/or completeness of Report information and submit consumer rebuttal
statement(s) on the consumer’s Report maintained by USIS.
Third parties may rely upon the representation of my agent as to all matters relating to any power
granted to my agent, and no person who may act in reliance upon the representations of my agent or
the authority granted to my agent shall incur any liability to me or my estate as a result of
permitting my agent to exercise any power.
This warranty shall bind my heirs, devisees and personal representatives. My Limited Power of
Attorney / Agent is authorized to seek on my behalf and at my expense: (a) a mandatory injunction
requiring compliance with my agent's instructions by any person, organization, corporation, or
other entity obligated to comply with instructions given by me, or (b) actual and punitive damages
against any person, organization, corporation, or other entity obligated to comply with instructions
given by me who negligently or willfully fails or refuses to follow such instructions.
Please return my reports to my Limited Power of Attorney,
facsimile # 1-866 813-4274
Signature____________________________________
Full Name (please print)
_________________________________________________________
SSN
DOB ____________________
Driver’s License # and State ____________________________
Address_______________________________
City ___________________________________ State
Zip
______________
__________________________
(
)
___________
Phone Number
-
Email address___________________________________
DACfix.com: LPA form 1008

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