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SIGNATURE:
DATE:
Before mailing, check to ensure you are providing all of the following documents:
This request form, fully completed and signed
Proof of Identity (see letter mailed to you with this form)
Proof of Mailing Address (see letter mailed to you with this form)
LexisNexis® Consumer Center
Attn: Accurint
P.O. Box 105610
Atlanta, GA 30348-5610
Accurint Report Request Form
Please Note:
Please provide all information requested, so that we may properly process your order.
You may only order information on yourself, a minor or someone whom you have Power of Attorney over.
You must be 18 years or older to request a file disclosure.
Send the completed order form, identification and address verification documents to the address above.
Section I: Consumer Information
FULL NAME:
Last Name
First Name
Middle Name
Suffix (Sr.,Jr.,III)
OTHER NAME(s) (past 10 years):
Last Name
First Name
Middle Name
Suffix (Sr.,Jr.,III)
Last Name
First Name
Middle Name
Suffix (Sr.,Jr.,III)
Date of Birth:
/ /
Social Security Number:
Month/ Day / Year
Section II: Address Information
CURRENT ADDRESS:
Apt Number
Street Number
Street Name
City
State
Zip Code
OTHER ADDRESS(s) (past 10 years):
Apt Number
Street Number
Street Name
City
State
Zip Code
Apt Number
Street Number
Street Name
City
State
Zip Code
Apt Number
Street Number
Street Name
City
State
Zip Code
Section III: Contact Information
Daytime Phone Number:
Evening Phone
Number:
Email
Address:
