USVI Public Records

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Nominee Release of Authorization Page |i S013 NOMINEE’S FULL NAME: Zz LOfite Jl / 7/7 AUTHORIZATION FOR RELEASE OF INFORMATION Carefully read this authorization to release information about you, then sign and date it in ink. 1. I Authorize an investigator, special agent, or other duly accredited representative of the authorized Local/Federal agency conducting my background investigation or reinvestigation to obtain any information relating to my activities from individuals, schools, residential management agents, employers, criminal justice agencies, credit bureaus, consumer reporting agencies, collection agencies, retailed business establishments, or other sources of information to include publicly available electronic information. This information may include but is not limited to my academic, residential, achievement, performance, attendance, disciplinary, employment history, and criminal history record information. I understand that, for some sources of information, a separate release will be needed, and I may be contacted for such a release at a later date. 2. I Authorize the Social Security Administration (SSA) to verify my Social Security Number (to match my name, Social Security Number, and date of birth with information in SSA records and provide the results of the match) to the United States Office of Personnel Management (OPM) or other Federal agency requesting or conducting my investigation for the purposes outlined above. I authorize SSA to provide explanatory information to OPM, or to the other Federal agency requesting or conducting my investigation, in the event of a discrepancy. 3. I Authorize custodians of records and other sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Local/Federal agency authorized above regardless of any previous agreement to the contrary. 4. J Understand that the information released by records custodians and sources of information is for official use by the Legislature of the Virgin Islands (Government) only for the purposes provided in this Application and that it may be disclosed by the Government only as authorized by law. 5. hereby consent and authorize the release of information on my character , background, ability, financial indebtedness and fitness to serve the residents of the United States Virgin Islands by all government Departments and agencies, especially the Bureau of Internal Revenue, Tax Assessor, Department of Justice Division of Paternity and Child Support, Board of Education, Economic Development Authority, U.S. Small Business Administration, Small Business Development Center, Police Department, Department of Licensing and Consumer Affairs, if applicable, employers, schools, all law enforcement agencies, and all other individuals and organizations which may be deemed necessary, to authorized Committee on Rules and Judiciary investigators, its staff and any other authorized employees of the Virgin Islands Government as may be required. Photocopies of this authorization with my signature are valid. This authorization is valid for two years from the date signed. "Gs, Last Four (4) Digits of SSN hl Nominee Release of Authorization Page|[2Z NOMINEE’S FULL wae AEon G7, /TH AUTHORIZATION FOR RELEASE OF INFORMATION Carefully read this authorization to release information about you, then sign and date it in ink. 6. CERTIFICATION: This document is to certify and affirm that all the statements contained herein and any supporting documents or schedules or other such supporting documents or schedules executed at a later date as a part or addendum to this document are true and correct to the best of my knowledge and are made in good faith. Sipned this £0 digruf’ SA 200 ZA Sg Core cen iH) ZX pile Nominee’s Name (Print Clearly) ignature of Nominee Sworn and Subscribed before me this Zod day of Sin ey, 20-2 eth? Notary Public [seal] i, Pala hs Fee My commission expires: i) “IS “PA mS ~ - ess Livia Valencia Blackwood Notary Public — = a=; NP-909-25 ee | SE ee, My Commission Expires: August 15, 2029 ay Se eae STT/STJ, U.S. Virgin Islands Last Four (4) Digits of SSN ii,