Form Gen 1390 - Informing Notice - Regarding An Action Taken On Your Case
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1STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COUNTY
INFORMING NOTICE –
REGARDING AN ACTION TAKEN
CASE NAME
ON YOUR CASE
CASE NO.
OTHER ID NO.
WORKER NAME
Date:_____________________
This form provides information about the report from a credit reporting agency used to make changes to your case.
A consumer credit report can verify employment, such as your wages, your salary, your hours worked or if and
where you are employed. This report is regulated by the Fair Credit Reporting Act.
The action taken on your case is explained on the enclosed form: ________________________________ .
Name of NOA, Etc., Used
“The action being taken against you is based in part from information obtained from the Consumer Credit Report Agency
listed below. This Agency did not make the decision to take this action against you and is not able to explain why the
decision was made. You can obtain a free copy of information contained in your file if you make a request to the Agency
within 60 days. You may dispute the accuracy or completeness of any information by contacting the Agency.”
The information to make this
change to your case was
provided by:
Name of Agency Providing Notice
How can you obtain a
By telephone: _______________________________________________________
copy of your employment
Toll-Free Number
verification report?
By mail: ____________________________________________________________
Address
On the web: _________________________________________________________
Website Address
You have a right to dispute any inaccurate information in your consumer credit report.
What if there are mistakes
in your consumer credit
Under Federal law, you have the right to obtain a copy of your consumer credit report
report?
without charge for 60 days after you receive this notice.
If you find mistakes in your consumer credit report, contact the consumer reporting
agency.
It is a good idea to check your consumer credit report to make sure the information
is correct.
How can you get more
For more information about consumer reports including this report, visit the Consumer
information about your
Financial Protection Bureau’s website at
employment verification
report?
County Worker Name: _________________________________________________
Please call your county
worker if you have any
Telephone Number: ___________________________________________________
questions about the
information in this notice.
GEN 1390 (3/17) REQUIRED FORM – NO SUBSTITUTES PERMITTED
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