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Sample ADVERSE ACTION NOTICE
Important disclaimer: The letter available on this page is an example of an FCRA compliant
disclosure. Please review and modify as necessary to fit your particular situation, and to comply
with the laws of your state.
CONSUMER DISCLOSURE
CONFIDENTIAL TO BE OPENED BY ADDRESSEE ONLY

APPLICANT NAME
11111 MAIN ST
WALNUT CREEK CA, 94598
Date
Dear Applicant:
This letter is to inform you that an offer of employment will not be made at this time. This
decision was based in whole or part, on the information provided us in a Consumer Report or
Investigative Consumer Report.
The report was prepared pursuant to an authorization signed by you at the time of application.
Subsequently you also received a copy of your Consumer Report and a Summary of your rights
under the Fair Credit Reporting Act. The Consumer Report was used only for employment
purposes and prepared for us by a Consumer-Reporting Agency. Their mailing address and
phone number are listed below:
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