Form DCSA 343 DCSA 343 Specific Authorization for Disclosure of Financial Infor

CUI

(when filled in)

Defense Counterintelligence and Security Agency (DCSA) SPECIFIC AUTHORIZATION FOR DISCLOSURE OF FINANCIAL INFORMATION					OMB No. OMB approval expires
The public reporting burden for this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or burden reduction suggestions to the Department of Defense, Washington Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number.
PRIVACY ACT STATEMENT Authorities: DCSA is authorized to seek this information based on section 925 of Public Law 115-91; and, Executive Order 13467, as amended by Executive Order 13869. Principal Purpose(s): To obtain records for investigating and determining an individual’s initial or continued: eligibility for access to classified national security information or assignment to positions with sensitive duties; suitability for enlistment or appointment into military service; suitability or, for employees in positions not subject to suitability, fitness for Federal employment; fitness for assignment to work under contract for or on behalf of the U.S. Government; or eligibility for physical or logical access to U.S. Government systems or facilities. Routine Use(s): The information collected may be disclosed to DCSA personnel and shared externally with other authorized government agency personnel, including those working for the agency requesting the investigation, as a routine use when necessary and relevant to personnel vetting investigations, determinations, and adjudications; and, for other purposes permitted under subsection (b) of the Privacy Act of 1974, as amended (5 USC §552a). Information obtained will also be released to the person being investigated upon their request unless otherwise exempt. A complete list of the routine uses can be found in the system of records notice for the Department of Defense Personnel Vetting Records System, “DUSDI 02-DoD” at: https://www.federalregister.gov/documents/2018/10/17/2018-22508/privacy-act-of-1974-system-of-records. Voluntariness: Your consent to this authorization is voluntary and the addressee’s disclosure of information is voluntary. Failure to consent or failure to provide DCSA access to the requested information may result in DCSA’s inability to conduct a thorough investigation and may prevent the government from making a determination or adjudication regarding the qualifications, suitability, eligibility or fitness of the person being investigated.
I, hereby authorize any duly accredited investigator or other duly accredited representative of the Defense Counterintelligence and Security Agency (DCSA) to obtain the information identified below, pertaining to me, which is maintained by the entity specified below:
FINANCIAL INSTITUTION:	ADDRESS:
Records Authorized to be Disclosed: I understand that by signing this authorization I am authorizing disclosure of all financial records regarding my account(s), including but not limited to, origination date, credit limit, payment history, current balance, collection actions, repayment agreements, and copies of any requested documents. The execution of this authorization is voluntary on my part and is made without duress or promise on the part of DCSA or other Federal investigative agency. I am aware that this release is valid only when presented to the addressee. This release is valid for three (3) months from the date signed below, unless revoked, or upon termination of my affiliation with the Federal Government, whichever is sooner. My signature herein, either handwritten or digital, is valid and should be accepted by the addressee. Photocopies of this authorization, with my signature, are valid. I have read and fully understand the Privacy Act Statement above and the Statement of Customer Rights under the Right to Financial Privacy Act of 1978 that follows on the next page of this form. I hereby release any individual, including record custodians, from any and all liability for damages of whatever kind or nature on account of compliance, or any attempts to comply, with this authorization. I voluntarily consent to the release of any and all financial information obtained with this release to any Federal agency that requests it after presentation of this release, consistent with the conditions of its collection under the Right to Financial Privacy Act, for employment suitability, fitness, or security clearance purposes.
SIGNATURE (handwritten or digital*)	FULL NAME						DATE SIGNED
OTHER NAMES USED		DATE OF BIRTH		SOCIAL SECURITY NUMBER
CURRENT STREET ADDRESS	CITY		STATE	ZIP CODE		PHONE NUMBER
(*) A valid digital signature complies with the Electronic Signature Act 15 U.S.C. 7001, Public Law 105-277 the Uniform Electronic Transaction Act, and other regulations governing electronic signatures and access-controlled U.S. Government systems. Controlled By: DCSA Controlled By: BI CUI Category: PRVCY LDC: POC: (571) 305-6562

DCSA FORM 343 Page 1 of 2

Statement of Customer Rights Under the

Right to Financial Privacy Act of 1978 (Title 12, U.S. Code, Chapter 35)

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 Release and Effects of Nondisclosure

Your authorization is voluntary and, in the case of financial records, may be revoked at any time before the information is released. You may revoke this authorization by writing to the financial institution you have identified on this form. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. In the case of financial records maintained at a financial institution (as defined by the Right to Financial Privacy Act), your authorization is not required as a condition of doing business with any financial institution. If you do not provide your authorization, however, the Defense Counterintelligence and Security Agency will not be able to obtain the requested data. Consequently, failure to furnish all or part of the information requested of you on the form may result in discontinuance of the investigation, and a lack of further consideration for employment, clearance or access, or in the termination of your employment.

Authorization

My signature on this release authorizes the release of financial records from financial institutions, as defined in the Right to Financial Privacy Act, 12 U.S.C. § 3401. By my signature, and in accordance with relevant provisions of the Right to Financial Privacy Act at 12 U.S.C.3404, I authorize disclosure of my financial records from the noted financial institution, or the assignee thereof, to the Defense Counterintelligence and Security Agency for the purpose of my investigation for a national security or public trust position. Further, I consent to the release of any and all financial information obtained with this release to any Federal agency that requests it for consideration in my eligibility for a national security or public trust position.

Records of Disclosures to Federal Agencies

Financial institutions are required to maintain a record of disclosure of financial data to Government authorities. Upon request, financial institutions must provide you with a copy of any record of their disclosure of your financial records to a Government authority, including the identity of the Government authority to which disclosure was made, unless the authority has obtained a court order delaying such.

a notice.

Transfer of Information by a Federal Authority

Generally, a Federal agency must tell you if any financial records pertaining to you, which were obtained from a "financial institution," are transferred to another Federal agency without your consent.

Penalties

If a 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 your suit is successful, you may be repaid reasonable attorney's fees and costs as determined by the court.

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DCSA FORM 343

CUI

(when filled in)