PROB 48E (Rev. 07/13) CUSTOMER CONSENT AND AUTHORIZATION FOR ACCESS TO FINANCIAL RECORDS FOR PRESENTENCE REPORT I, (Name of Customer) , having read the explanation of my rights, which is attached to this form, and having been convicted in the U.S. District Court, in accordance with Rule 32(d)(2)(A)(ii) (and 18 U.S.C. § 3664(d)(3) when restitution may be imposed), hereby authorize the (Name and Address of Financial Institution or Credit Agency) to disclose the following financial records: to (Name of Probation Officer Allowed Access) , an officer of the , (Name of District Court) U.S. District Court for the to obtain information on assets I own or control, fully describing my financial resources to the United States probation officer for the purpose of preparing a presentence investigation report. 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 for no more than three (3) months from the date of my signature. 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) (Social Security Number of Customer) (Date of Birth 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). Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com PROB 48E (Rev. 07/13) STATEMENT OF CUSTOMER RIGHTS UNDER THE RIGHT TO FINANCIAL PRIVACY ACT OF 1978 Federal law protects the privacy of your financial records. Before banks, savings and loan associations, credit unions, credit card issuers, or other financial institutions may give financial information about you to a federal agency, certain procedures must be 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 be revoked in writing at any time before your records are disclosed and, in any event, is effective for a period of not more than three months. 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 been obtained 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 a lawful 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 notice beforehand. In situations where you do not receive advance notice that the government is seeking your financial records, you will be notified 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 Federal agency unless it certifies in writing that the transfer is proper and sends a notice to you that your 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 to seek compliance with the law. If you win, you may be repaid your attorney's fees and costs. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com