OPROB 48I (09/00) CUST OMER CONS ENT AN D AUTHOR IZ ATI ON FOR ACC ESS TO FI NANCI AL REC ORDS D URI NG S UPER VIS ION I, , having read the explanation (Name of Customer) of my rights which is attached to this form, and having been convicted in the United States District Court, and in accordance with 18 U.S.C. 3603, I am required to provide complete disclosure of all assets I own or control, fully describe my financial resources to the United States probation officer for the purpose of probation or supervised release supervision ordered at sentencing, and hereby authorize the (Name and Address of Financial Institution or Credit Agency) to disclose the following financial records: to , an officer of the (Name of Probation Officer Allowed Access) United States District Court for the , (Name of District Court) for the purpose of keeping the probation officer informed concerning compliance with any condition of supervision, including the payment of any criminal monetary penalties imposed by the court, and that this financial information may be transferred to the financial litigation unit of the United States attorneys office for the purpose of the collection of financial penalties. I understand that this authorization may be revoked by me in writing at any time before my records, as described above, are disclosed, and that this authorization is valid from the date of my signature until my release from supervision. I understand further that my authorization cannot be required as a condition of my doing business with the above-named financial institution. (Date) (Signature of Customer) (Address of Customer) (City/State/Zip Code) Section 1104(a) of the Right to Financial Privacy Act, 12 U.S.C. 3404(a). >>>> 2OPROB 48I (09/00) Page 2 STATEMENT OF CUSTOMER RIGHTS UNDER THE RIGHT TO F INAN CIAL P RIVA CY A CT O F 1978 (Disclosure to Financial Institutions, But Not Credit Agencies) Federal law protects the privacy of your financial records. Before banks, savings and loan associations, credit unions, creditcard issuers, or other financial institutions may give financial information about you to a federal agency, certain procedures mustbe followed. Consent to Financial Records You may be asked to consent to make your financial records available to the government. You may withhold your consent,and your consent is not required as a condition of doing business with any financial institution. If you give your consent, it can berevoked in writing at any time before your records are disclosed and, in any event, is effective for a period of not more than threemonths. Your financial institution must keep a record of the instances in which it discloses your financial information to the government, and this record will be available to you upon request, unless a court order restricting your right to such record has beenobtained by the government. Without Your Consent Without your consent, a Federal agency that wants to see your financial records may do so ordinarily only by means of alawful subpoena, summons, formal written request, or search warrant for that purpose. Generally, the Federal agency must give you advance notice of its efforts to obtain your records by one of the above means,explaining why the information is being sought and telling you how to object in court to the release of your records. Exceptions If the government obtains a search warrant for your records, or if the government convinces the court that there are legitimate reasons to delay giving you notice, the Federal agency will be able to obtain your records without providing you noticebeforehand. In situations where you do not receive advance notice that the government is seeking your financial records, you will benotified once the reason for the delay of notice no longer exists. Transfer of Information Generally, a Federal agency which obtains your financial records is prohibited from transferring them to another Federalagency unless it certifies in writing that the transfer is proper as noted on the reverse side of this form and sends a notice to you thatyour records have been sent to another agency. Penalties If the Federal agency or financial institution violates the Right to Financial Privacy Act, you may sue for damages or toseek compliance with the law. If you win, you may be repaid your attorneys fees and costs.