Report Request Form Page 2
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1
2REPORT REQUEST FORM
Obtaining information under false pretenses is illegal. Obtaining a consumer report on someone
other than you is punishable by law and can result in fines and/or imprisonment.
To process your request for your consumer report from MicroBilt, we need the following
information:
Last Name: ________________________ First and Middle Name: _____________________________
Maiden Name or other last names used: __________________________________________________
Social Security No.: __________________ Driver’s License No. / State: _________________________
DL copy attached; OR two other forms of identification attached
(
)
Current Street Address: ________________________________________________________________
City, State & Zip: _____________________________________________________________________
Home Phone #: ____________________________
Previous addresses you have had in the past five years:
Previous Street Address #1: ____________________________________________________________
City, State & Zip: _____________________________________________________________________
Previous Street Address #2: ____________________________________________________________
City, State & Zip: _____________________________________________________________________
If applicable:
Credit Declined Date: _________________ Name of Company: _______________________________
Social Security Number:
If you would like us to redact your social security number from the report we send you, check the box.
Important: This Form will not be considered complete unless you have signed your name below
and included a copy of your Driver's License or two of the alternative forms of identification listed
on the attached cover letter.
Signature: ______________________________ Date: _________________
Order by Mail: Microbilt
Attention: Consumer Affairs Department
P.O. Box 440693
Kennesaw, GA 30160
To help prevent identity theft and fraud, please note that your consumer report will be sent only to the
CURRENT address shown on your consumer report in our databases.
Microbilt, P.O. Box 440693, Kennesaw, GA 30160
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