Iso Claimsearch - Request For Disclosure To Third Parties printable pdf download

Iso Claimsearch - Request For Disclosure To Third Parties

ISO CLAIMSEARCH

545 WASHINGTON BOULEVARD, JERSEY CITY, NJ 07310-1686

TEL: (201) 469-3097

FAX: (201) 469-4139

Request for Disclosure to Third Parties

Name: ________________________________________________________________________

Present Address: ________________________________________________________________

Previous Addresses: ____________________________________________________________

____________________________________________________________

Date of Birth: ______________________________

SSN: ________________________

I am the person named above and I understand that Federal Law provides that a person who obtains

information from ClaimSearch under false pretenses may be fined not more than $5,000 or

imprisoned not more than 1 year or both. I will understand that if ClaimSearch is unable to

establish proper identification, it will be obliged to decline my request for disclosure.

Attorney: __________________________________

Law Firm: Levinson Axelrod, P.A.

□ 2 Lincoln Highway, P.O. Box 2905, Edison, NJ 08840

732-494-2727

□ 274 Church Street, Belford, NJ 07718

732-787-3200

□ 124 Route 31, Flemington, NJ 08822

908-782-6766

□ 654 Lacey Road, Forked River, NJ 08731

609-971-1177

□ 302 Route 206, Hillsborough, NJ 08844

908-359-0110

□ 3641 Route 9 North, Howell, NJ 07731

732-730-9600

□ 220 Forsgate Drive, Jamesburg, NJ 08831

732-656-3650

Client Signature: _____________________________________

Date: ___________________

Return to: ISO ClaimSearch, ATTN: Denise Fasano, 545 Washington Blvd 22-8, Jersey City, NJ 07310-1686

Include $65 fee (payable to AISG) and a copy of client’s driver’s license or photo ID

Iso Claimsearch - Request For Disclosure To Third Parties