711 E Henderson Ave.

Tampa, FL 33602

BRYAN BUSTAMANTE
421 ELISTON ST
SUMMERVILLE, SC 29486-0402

Date of Notice 7/17/2023

NOTICE OF ACTION BASED ON INFORMATION CONTAINED IN A CONSUMER REPORT

We regret we cannot open your account today due to information received from ChexSystems, Inc., a consumer-
reporting agency. ChexSystems did not make the decision to disapprove your account application and is unable
to provide you with specific reasons why the decision was made.

You have rights under state and federal laws. Included in these rights are:
> The right to obtain a free copy of your ChexSystems consumer report if you make such a request to
ChexSystems within 60 days of your receipt of this notice; and
> The right to dispute the completeness or accuracy of any information contained in such report by notifying
ChexSystems directly of your dispute.

You may contact ChexSystems by telephone using their voice messaging system at 800-428-9623, by mail
at ChexSystems, Attn: Consumer Relations, P.O. Box 583399,Minneapolis, MN 55458; or by web at www.
ChexSystems.com.

TO ENABLE CHEXSYSTEMS TO PROPERLY ASSIST YOU, YOU WILL NEED TO SUPPLY THEM
WITH THE INFORMATION REQUESTED BELOW AND/OR ON THE REVERSE SIDE.

PLEASE COMPLETE THIS FORM.

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To enable ChexSystems to properly assist you, please provide them with the following information.
* Indicates a required field

Full Name
FIRST NAME MIDDLE NAME LAST NAME

Maiden Name or Other Last Names Used:

*U.S. Social Security Number *Date of Birth

M/D/Y

U.S. Drivers License Number State of Issuance

Daytime Telephone Number ( )

*Current Address
NUMBER & STREET CITY STATE ZIP CODE

ChexSystems will correspond with you at the above address unless you request otherwise
*Any previous addresses used in the past five years (include any P.O. Boxes):

NUMBER & STREET / APT # CITY STATE ZIP CODE

NUMBER & STREET / APT # CITY STATE ZIP CODE

If you wish to obtain information on any business accounts you have signed on within the past five years, please
list the business name, tax ID number & address as well as your title/relationship to the business.

BUSINESS NAME TAX ID #

YOUR TITLE BUSINESS ADDRESS CITY STATE ZIP CODE

BY SUBMITTING YOUR PERSONAL INFORMATION TO CHEXSYSTEMS, YOU ACKNOWLEDGE YOUR

AGREEMENT TO PROVIDE ACCURATE IDENTIFYING INFORMATION AND YOUR UNDERSTANDING THAT
CHEXSYSTEMS MAY ACCESS, STORE, AND USE THIS INFORMATION TO THE EXTENT PERMITTED BY LAW.

*SIGNATURE DATE

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