Fillable Printable Form 4030 Authorization For Release Of Information
Fillable Printable Form 4030 Authorization For Release Of Information
Form 4030 Authorization For Release Of Information
STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT
AUTHORIZATION FOR RELEASE OF INFORMATION (MONEY TRANSMITTERS)
DBO-4030 (Rev. 5-17)
(Name of Applicant)
(hereinafter referred to as the "Applicant"), which is applying for a license under the
California Money Transmission Act (California Financial Code, Division 1.2, commencing
with Section 2000), hereby irrevocably authorizes any bank or other financial institution
with which the Applicant may at any time transact business and any governmental agency
which licenses or regulates money transmitters or other financial institutions and which at
any time has information or records regarding the Applicant, to furnish to the
Commissioner of Business Oversight of the State of California such information, and to
permit her/him to inspect and copy such records, as she/he may request from time to time.
Dated:
(Name of Applicant)
By
(Signature)
(Name and Title)
(Note: The signature of the Applicant must be acknowledged.)
STATE OF CALIFORNIA –DEPARTMENT OF BUSINESS OVERSIGHT
AUTHORIZATION FOR RELEASE OF INFORMATION (MONEY TRANSMITTERS)
DBO-4030 (Rev. 5-17)
DBO’s Privacy Notice on Collection
DBO Collects and Uses Personal Information: The DBO collects the information
requested on this form as authorized by Financial Code section 2032(c)(22). The DBO uses
this information evaluate an application for a money transmitters license. Use of the personal
Information DBO collects is subject to limitations contained in the Information Practices Act of
1977 and other applicable state and federal laws.
Providing Personal Information Is Mandatory. When providing information or documents,
please do not include unrequested personal information such as a Social Security number,
driver’s license number, or financial information.
DBO May Disclose Your Personal Information: We may share your personal information
with other state departments, federal government or law enforcement. Your personal
information may also be disclosed:
In response to a Public Records Act request, as allowed by the Information Practices
Act.
To another governmental agency as required by state or federal law.
In response to a court order or administrative order, a subpoena or a search warrant.
Your Access to Your Personal Information: You may review the records maintained by
DBO that contain your personal information. To request access, contact: DBO Privacy
Officer, 1515 K Street, Sacramento, CA 95814,
(866) 275-2677.
