Pt. 275, App. I
Appendix I to Part 275—Format for Obtaining Basic Identifying Account Information
Chief Teller [as appropriate]
First National Bank
Anywhere, VA 00000-0000
Dear Mr./Mrs. XXXXXXXXXX
In connection with a legitimate law enforcement inquiry and pursuant to section 3413(g) of the Right to Financial Privacy Act of 1978, 12 U.S.C. 3401 et. seq., you are requested to provide the following account information:
[Name, address, account number, and type of account of any customer or ascertainable group of customers associated with a financial transaction or class of financial transactions.
I hereby certify, pursuant to section 3403(b) of the Right of Financial Privacy Act of 1978, that the provisions of the Act have been complied with as to this request for account information.
Under section 3417(c) of the Act, good faith reliance upon this certification relieves your institution and its employees and agents of any possible liability to the customer in connection with the disclosure of the requested financial records.
[Official Signature Block]