Consent for disclosure of records protected under the Privacy Act

This form may be used to provide consent and authorize the CFPB to disclose your records to another person or entity. Please provide the information requested below and submit.

This form may be used if you are:

Providing consent and authorizing the CFPB to disclose your records to another person or entity
A parent consenting to and authorizing the disclosure of the records of a minor
A legal guardian consenting to and authorizing disclosure of the records of an incompetent

If you have any questions, please contact the CFPB’s FOIA Office at FOIA@cfpb.gov or at (855) 444-3642.

Information used for identity-proofing and authentication

Please provide the following information to assist the CFPB in verifying your identity:

Required

Full name
Electronically signed statement (at the bottom of this form) that affirms your identity and the fact that you understand penalties associated with requesting information under false pretenses

Optional

A photocopy of two forms of identification, including one form of identification that bears your photograph, and one form of identification that bears your signature; or
A photocopy of a single form of identification that bears both your photograph and signature

For requests by parent or legal guardian

If you are the parent consenting to and authorizing disclosure of the records of a minor or the legal guardian consenting to and authorizing disclosure of the records of an incompetent, you will be required to provide adequate proof of your legal relationship before action will be taken on any request. If you have any questions, please contact the CFPB’s FOIA Office at FOIA@cfpb.gov or at (855) 444-3642.

The term guardian means the legal guardian of any individual who has been declared to be incompetent due to physical or mental incapacity or age by a court of competent jurisdiction.

Information required to locate the records

This information is required for the CFPB to be able to match the individual's information provided in this request with the record that pertains to that individual.

See list of CFPB System of Records Notices (SORNs)

Description of the record(s) sought

Additional information that might assist in locating the records

This enables the CFPB to locate the system of records containing the record(s) with a reasonable amount of effort.

Name of the system of records you believe contain the record(s) (optional)

Date of the record(s) (optional)

Or the period in which you believe that the record was created

Any additional information (optional)

This may include maiden name, dates of employment, account information, etc.

Contact information

Please provide your contact information so that we can correspond with you regarding the request.

Requestor contact information

Name of requestor

Email address

Recepient contact information

Name of recipient

Email address

Please send my records via email

Please send my records by mail

If you would like to receive your records by mail, please provide your mailing address.

Street address

City

State

Zip

Supporting documentation (optional)

Identity verification documents:

A photocopy of two forms of identification, including one form of identification that bears your photograph, and one form of identification that bears your signature; or
A photocopy of a single form of identification that bears both your photograph and signature

Select files to attach

Please select up to 6 files. The total file size must not exceed 6MB. We accept all image files, including .jpg, .png, .pdf, .gif and .eps.

Files added:

To remove or replace files, click “Select files to upload” and upload again.

Consent for disclosure of records

I declare under penalty of perjury under the laws of the United States of America that the foregoing is true and correct, and that I am the person named above and consenting to and authorizing disclosure of my records, or records that I am entitled to request as the parent of a minor or the legal guardian of an incompetent, and I understand that any falsification of this statement is punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of not more than five years, or both, and that requesting or obtaining any record(s) under false pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more than $5,000.

Full name

Privacy Act statement