OMB No. 1513-0004 (9/30/2009)
the
DEPARTMENT OF THE TREASURY-ALCOHOL AND TOBACCO TAX AND TRADE BUREAU
AUTHORIZATION TO FURNISH FINANCIAL INFORMATION
AND
CERTIFICATE OF COMPLIANCE
(Right to Financial Privacy Act of 1978)
SECTION A: CUSTOMER AUTHORIZATION (12 U.S.C. 3404) TO BE COMPLETED BY CUSTOMER
having read the explanation of my rights below on this form, hereby
I,
authorize the following financial institution to disclose the financial records specified below
, and any and all information pertaining to those financial
records to the Alcohol and Tobacco Tax and Trade Bureau.
NAME OF FINANCIAL INSTITUTION AND PERSON TO CONTACT (IF KNOWN)
CITY, STATE, AND ZIP CODE
STREET ADDRESS
CHECKING ACCOUNT NUMBER AND NAME ON THE ACCOUNT
SAVINGS ACCOUNT NUMBER AND NAME ON THE ACCOUNT
LOAN NUMBER AND NAME(S) APPEARING ON THE LOAN
OTHER (SPECIFY)
.
PURPOSE FOR WHICH DISCLOSURE IS NECESSARY
I understand that this authorization may be revoked by me in writing at any time before my records, as described above, are disclosed and that this
authorization is valid for no more than three (3) months from the date of my signature.
DATE
SIGNATURE OF CUSTOMER
ADDRESS OF CUSTOMER
SECTION B: CERTIFICATE OF COMPLIANCE BY TTB OFFICIAL
(12 U.S.C. 3403(b))
DATE OF REQUEST
NAME OF FINANCIAL INSTITUTION OFFICIAL AND TITLE
I hereby certify that the applicable provisions of the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401-3422, have been complied with and the good faith reliance upon this
certificate relieves your institution and its employees and agents of any possible liability to the customer in connection with the disclosure of these financial records.
SIGNATURE OF TTB OFFIC IAL
ADDRESS
TELEPHONE NUMBER (Including Area Code)
NAME AND TITLE OF TTB OFFICIAL
TTB F 5030.6 (08/2008)