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CCB-1149 DEPOSITORY INSTITUTION AUTHORIZATION FORM Instructions This form is to be completed by an authorized principal or officer of the applicant in order to authorize the addressed financial institution to provide information to this Bureau regarding the history of its account relationship s with the applicant. If the applicant is a start-up company or has accounts that have been open less than one year this form should authorize the addressed institution to provide account relationship information for the principals members partners or trustees of the applicant with one form to be completed per individual. If the applicant is a sole proprietorship this form should authorize disclosure of all account relationship information of the proprietor. TO Name of Bank Street Address City State Zip ATTN Contact Person and Title - Optional Phone Number If Applicable FROM Full Name of Company or Individual Name of Account Holder or Authorized Signer any and all information regarding all of the active and closed depository or loan accounts of Name of Company or Individual but not limited to the opening date of the account s the name s in which the account s is are titled the current and average balance s whether there are any liens or encumbrances on deposited funds any overdraft history and loan payment history. If the applicant is a start-up company or has accounts that have been open less than one year this form should authorize the addressed institution to provide account relationship information for the principals members partners or trustees of the applicant with one form to be completed per individual* If the applicant is a sole proprietorship this form should authorize disclosure of all account relationship information of the proprietor. TO Name of Bank Street Address City State Zip ATTN Contact Person and Title - Optional Phone Number If Applicable FROM Full Name of Company or Individual Name of Account Holder or Authorized Signer any and all information regarding all of the active and closed depository or loan accounts of Name of Company or Individual but not limited to the opening date of the account s the name s in which the account s is are titled the current and average balance s whether there are any liens or encumbrances on deposited funds any overdraft history and loan payment history. .

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