Credit Bureau Systems

Credit Report

On-Line Request for Disclosure of Credit Report

Consumer Services Group
A Division of Credit Bureau Systems, Inc.
P O Box 9200
Paducah, KY 42002-9200

Please complete the identifying information section below, indicate the service level requested, and check the Acceptance Box to acknowledge your understanding and acceptance of the terms of our services. By checking the acceptance box and submitting this on-line request to Credit Bureau Systems you are authorizing us to obtain and provide you a copy of credit report and you are certifying that you are the person listed below. You are also certifying that you understand that Federal Law provides that a person who obtains credit information under false pretenses shall be fined not more than $5,000 and/or imprisoned not more than one year.

Personal Information

*Name:
*Address:
*City:
*State:
*Zip:
*Phone:
*Email:
*Social Security #
*Date of Birth:
*EMPLOYER:

Spouse Information

COMPLETE THE FOLLOWING ONLY IF SPOUSE DISCLOSURE IS REQUESTED
Spouse Name:
Spouse Social Security #
Spouse Date of Birth:
Spouse Employer (If Any):

Service Level Requested

	$10.00 - Individual Report / Copy Only
	$20.00 - Individual and Spouse
	$29.95 - Individual Copy Plus Decoding of Creditors Copies Only
	$32.95 - Credit Report and Private In Person Consultation
	$42.95 - Copy of Report In Person Consultation Re-Investigation & Dispute
	Additional $5.00 - Provide My Credit Score on My Report

By indicating my acceptance of the terms and submitting this on-line form, I request written/telephone disclosure of the nature and substance of all information on me, including the source of the information unless investigative that is contained in my credit report as recorded by The Trans Union Credit Information Company. . I acknowledge that Credit Bureau Systems has informed me of the charges for this service and agree to pay in accordance with the listed prices. I am the person named above and I understand that Federal Law provides that a person who obtains credit information under false pretenses shall be fined not more than $5,000 or imprisoned not more than one year or both. In the event that information in my file is inaccurate, in my opinion, I understand that I have a right to dispute such information by sending written notice of my dispute to Trans Union at #2 Baldwin Place, Chester, PA 19022 or by contacting Credit Bureau Systems Consumer Services Group and requesting that they provide such dispute services on my behalf. I understand that additional charges may apply if I request assistance from Consumer Services Group in connection with my dispute of any item on the credit report. I understand that my credit score is not considered a part of a credit report and that if I wish to obtain my credit score I must pay an additional charge of $5.00.

Yes, I accept these terms.