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Sample Adverse Action Notice
City, State Zip
Dear [Applicant]:
We regret to inform you that we have found it necessary to reject your application for
This action was influenced by information in a consumer report made, at our request, by
XYZ Company, Street Address, City, State, Zip, Phone.
XYZ did not make the adverse decision and cannot provide the reason for the decision.
You may obtain a free copy of the report within 60 days and you have the right to dispute
the accuracy of the information with Application Profiles.

[Human Resource Manager]
Credit Report
Summary of Your Rights under the Fair Credit Reporting Act