Appendix A to Part 504 - Request For Basic Identifying Account Data - Sample Format

Appendix A to Part 504 - Request For Basic Identifying Account Data - Sample Format

(Official Letterhead)

(Date)

Mr./Mrs. _____

Chief Teller (as appropriate), First National

Bank, Little Rock, AR 72203.

Dear Mr./Mrs. _____: In connection with a legitimate law enforcement inquiry and pursuant to section 3414 of the Right to Financial Privacy Act of 1978, section 3401 et seq., Title 12, United States Code, you are requested to provide the following account information: (name, address, account number, and type of account of any customer or ascertainable group of customers associated with a certain financial transaction or class of financial transactions as set forth in § 504.1(f)).

I hereby certify, pursuant to section 3403(b) of the Right to Financial Privacy Act of 1978, that the provisions of the Act have been complied with as to this request for account information.

(Official Signature Block) ___

Under section 3417(c) of the Act, good faith reliance upon this certification relieves your institution and its employees and agents of any possible liability to the subject in connection with the disclosure of the requested financial records.