Hickman & Associates
Post Office Box 21, Guthrie, Oklahoma 73044
Local (405) 229-4635
PERMISSIBLE PURPOSE FORM
[ ] For use that is in the legal or beneficial interest relating to the subject. Please include subject's signature of approval.
By signing this document you declare that all of the information you have given is true and accurate. In addition, you declare that your reasons for requesting this information are for legal purposes only and that you have no intention to use the information obtained through this request for fraudulent purposes, illegal or otherwise. You understand that for Comprehensive Reports we must charge a fee regardless of whether any results are returned or not. The fee is for the research of the information.
Applicant’s Signature X___________________________________________________
Complete this form and fax to (405)282-1329
There are many legitimate reasons for obtaining a person's social security number, address, date of birth or other personal information about another person. We simply need to know what yours is before we can proceed with your order.
[ ] For use in comploying with federal, state, or local laws, rules, and other applicable legal requirements. Please cite exact case law.
[ ] For use for any of the following purposes as they relate to consumer insurance: account administration, reporting, investigating, preventing fraud or material misrepresentation, processing insurance claims, or as otherwise required or specifically permitted under federal or state law. Please provide supporting documentation.
[ ] For use as necessary to effect, administer, or enforce a transaction requested or authorized by the subject, including location for collection of a delinquent account. Please provide supporting documentation.
[ ] For use in complying with a properly authorized civil, criminal, or regulatory investigation, subpoena, or summons by federal, state, or local authorities. Please provide supporting documentation including case number.
[ ] For use to protect against or prevent actual or potential fraud, unauthorized transactions, claims, or other liability. Please provide supporting documentation.
[ ] For use by any government agency, or any officer, employee, or agent of such agency in carrying out official government duties or obligations by a federal, state, or local government agency. Please provide necessary authorizations.
[ ] For any other use permitted or otherwise not restricted by law and which may reasonably be expected to be part of the normal course and scope of your business or profession or for use for any non-business client. Please provide explaination below.
SUPPORTING INFORMATION:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
YOUR NAME: _______________________ COMPANY NAME: _______________________
ADDRESS: _________________________________________________________________
PHONE: (_____)_______-_________ E-MAIL: _____________________________________
Full Legal Name of Subject (please print) _________________________________________
Alias/Maiden: _____________________________________________________________
Social Security No. _____-_____-_____ Date of Birth _____/_____/_____
Current Address: ____________________________________________________________
City ___________________ State __________________ Zip Code ____________________