Consumer Report Copy Request Form

Company Name^*?   I don't know

Approximate time the report was issued^*  —Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember —Please choose an option—20122013201420152016201720182019202020212022

?  Info Cubic can provide a copy of your background report if our client conducted a background check on you in the past. Because Info Cubic does not maintain a universal database of consumer credit reports, we will not have your individual consumer report on file if you have not previously submitted an application to our clients and authorized a background report.

Section B: Consumer Information

Date Of Birth*  

Do you have a Social Security Number? Last 4 digits^*

State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest-VirginiaWisconsinWyomingOthers

Report Delivery Preference:^*  —Please choose an option—E-mailFaxMail

If the identifiers provided do not match what is in our system, we will contact you for additional identification before processing your request.

Section C: Authorization Release

Please complete the following release to authorize the copy request.

Pursuant to the Fair Credit Reporting Act, I authorize Info Cubic to provide me with a copy of my consumer report. I certify that I am the consumer requesting the report as identified in Section B of this form and that all information provided on this form is complete and accurate.

Date: