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O: Formal Written Request for Account Information and Certificate of Compliance With the—Form DOJ-475

RFPA Form DOJ-475--Formal Written Request for Account Information and Certificate of Compliance With the UNITED STATES DEPARTMENT OF JUSTICE Washington, D.C. 20530 FORMAL WRITTEN REQUEST FOR ACCOUNT INFORMATION AND CERTIFICATE OF COMPLIANCE WITH THE RIGHT TO FINANCIAL PRIVACY ACT TO: ____________________________________________ (Name and Address of Financial Institution) FROM: _____________________________________________ (Name and Address of Government Agency) In connection with a legitimate law enforcement inquiry and pursuant to Section 1113(g) of the Right To Financial Privacy Act of 1978, 12 U.S.C. Section 3413(g), you are requested to provide the following account information: I hereby certify, pursuant to Section 1103(b), the Right To Financial Privacy Act of 1978, 12 U.S.C. Section 3403(b), that the provisions of the Act have been complied with as to this request for account information and that 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 this account information. ______________________________ (Name and Title of Official) ______________________________ (Signature) ___________ ___ l9 __ (Date) __________________________ (Government Agency) Remarks: Sec. 1113(g) of the Right To Financial FORM DOJ-475 Privacy Act, l2 U.S.C. Sec. 3413(g)