Form

Last name*

Middle Name

First name*

Other Names used (including maiden name)

Last 4 Digits of SSN*

Date of birth*

Street address*

City*

State/Region*

Zip Code*

Home Phone*

Mobile Phone

Work Phone

Email*

By checking this box, I agree and consent to receiving electronic communications including, but not limited to, documents, notices and disclosures, which AccuSource, Inc. provides in connection with my consumer report. I understand that I also have the option to receive this communication via United States Postal Mail if requested, but unless otherwise specified; all communication regarding my dispute will be delivered and received via electronic communication.

AUTHORIZATION FOR REINVESTIGATION OF CONSUMER DISPUTE
You have requested that AccuSource, Inc. reinvestigate the consumer report that was conducted on you. By acknowledging below, you hereby authorize without reservation, any party or agency contacted by AccuSource, Inc., to furnish any information needed to complete the reinvestigation of your consumer dispute. Further, you understand this release will permit any present or former employer, school, police department, criminal record depository, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about you to furnish AccuSource, Inc. with any and all background information in their possession regarding you, that is required to complete the reinvestigation of your consumer dispute.

You also agree that a fax or photocopy of this authorization be accepted with the same authority as the original.

Type your First and Last Name*

Last 4 Digits of Social Security Number

Date of Birth (DOB)*

I wish to dispute the accuracy and/or completeness of the information appearing in my consumer report concerning the screening elements that I have checked below.

Please provide a detailed explanation of the information that you are disputing:*

Upload additional supporting documentation if applicable

TransUnion Consumer Dispute Information:

If you are disputing information specifically related to the Credit Report contained in your background screening report, you will need to complete and provide the following additional pages.

Company Name #1

Account #

This information is inaccurate because:

INVESTIGATIVE OWNERSHIP: (choose only 1)

I have no knowledge of this account

This is not my account, it belongs to a relative or person with similar name/address

I am no longer liable for this account

I am no longer liable for this account per divorce decree

Creditor agreed to remove my liability on this account

This account was fraudulently opened by someone who stole my identity

NOTE: You may also add additional comments in the space provided below. Please be aware that you expressly consent to TransUnion sharing any comments that you provide with data furnishers.

Company Name #2

Account # (#2)

This information is inaccurate because:

INVESTIGATIVE OWNERSHIP: (choose only 1) #2

I have no knowledge of this account

This is not my account, it belongs to a relative or person with similar name/address

I am no longer liable for this account

I am no longer liable for this account per divorce decree

Creditor agreed to remove my liability on this account

This account was fraudulently opened by someone who stole my identity

NOTE: You may also add additional comments in the space provided below. Please be aware that you expressly consent to TransUnion sharing any comments that you provide with data furnishers.

Company Name #3

Account # (#3)

This information is inaccurate because:

INVESTIGATIVE OWNERSHIP: (choose only 1) #3

I have no knowledge of this account

This is not my account, it belongs to a relative or person with similar name/address

I am no longer liable for this account

I am no longer liable for this account per divorce decree

Creditor agreed to remove my liability on this account

This account was fraudulently opened by someone who stole my identity

NOTE: You may also add additional comments in the space provided below. Please be aware that you expressly consent to TransUnion sharing any comments that you provide with data furnishers.

Please use this space for corrections to your previous address information, corrections to your previous employer information and for additional comments (Optional):

By checking this box, I confirm there are no other items on this dispute form that have not been addressed above.*