Reference and Background Check Disclosure and Authorization

588 E. Santa Fe, Suite 3000 Olathe, Kansas 66061

The Johnson County Government conducts reference and background checks in evaluating and verifying qualifications for employment, modifying or continuing ongoing employment, entering into independent contractor relationships, screening volunteers for particular services, and related public safety and risk management assessments. The Johnson County Government or its agents may obtain background information, including criminal record history information, driving history, education, prior employment history, military service, professional licensure records, government records, credit standing, and other types of background information, from others as necessary to properly evaluate employees, applicants, contractors, and volunteers. Any person who provides misleading, erroneous, or willfully deceptive information or who fails to reveal material information to the Johnson County Government will be eliminated from further consideration for employment, will be subject to termination of employment if employed prior to discovery, or may have any contract they have entered into with Johnson County terminated. The Fair Credit Reporting Act gives you specific rights when third party consumer agencies provide these types of reports to the County. A separate document is enclosed summarizing those rights. Before making any decision which is based on the information contained in reports from a third party consumer agency, the County will provide you with a copy of the report and a written description of your rights under the Fair Credit Reporting Act.

As part of its risk management process, Johnson County periodically checks the motor vehicle records of employees who operate county vehicles. In addition, the County also reviews the motor vehicle records of individuals who are required to maintain a valid driver’s license as a condition of employment. In order to comply with state and federal law, the County is required to run a criminal history check for certain positions. These types of records are covered by the Fair Credit Reporting Act when obtained from a third party consumer agency.

The information requested below is for the purpose of conducting the background investigation. It is the policy of the Johnson County Government not to discriminate against any employee or applicant because of race, color, sex, religion or creed, age, disability, pregnancy, ancestry or national origin, genetic information, military status or membership or service in the military, or other legally protected status.

jocogov.org/hr @jocogov f/Johnson County Human Resources

111 S. Cherry Street, Suite 2600 Olathe, Kansas 66061

I hereby authorize and request any present or former employer, school, law enforcement agency, state or federal agency, financial institution, division of motor vehicles, consumer reporting agency, or other persons or agency having knowledge about me to furnish it to Johnson County Government or its designated representative with any and all background information in their possession regarding me, so that my employment or service qualifications may be evaluated and/or reassessed. I hereby relieve all agencies and individuals connected with this information from any claim or liability for providing this information. I also agree that a fax, digital image, or photocopy of this authorization with my signature shall have the same authority as the original.

By signing below, I certify (1) that I have read and fully understand this disclosure and authorization; (2) that all of the information I am providing is true and accurate; (3) that any answers contrary to the truth may be grounds for dismissal or refusal to hire and that nothing has been withheld that would affect my employment and (4) that I have received the attached Summary of Your Rights and the Fair Credit Reporting Act.

jocogov.org/hr @jocogov f/Johnson County Human Resources

111 S. Cherry Street, Suite 2600 Olathe, Kansas 66061

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records Here is a summary of your major rights under the FCRA.

For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer

Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address, and phone number of the agency that provided the information.

You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your “file disclosure” You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

• you are the victim of identity theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.

A person has taken adverse action against you because of information in your credit report;

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See for an explanation of dispute procedures. www.consumerfinance.gov/learnmore

Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need -- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the . trucking industry. For more information, go to www.consumerfinance.gov/learnmore

You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.

You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

Identity theft victims and active duty military personnel have additional rights. For more information, visit . www.consumerfinance.gov/learnmore

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For information about your federal rights, contact:

jocogov.org/hr @jocogov f/Johnson County Human Resources

588 E. Santa Fe, Suite 3000 Olathe, Kansas 66061

1.a. Banks, savings associations, and credit unions with total assets of over 10 billion and their affiliates

a.Consumer Financial Protection Bureau 1700 G Street NW Washington, DC 20552

b.Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB

b.Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877)382-4357

To the extent not included in item 1 above: a.National banks, federal savings associations, and federal branches and federal agencies of foreign banks

a.Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450 Houston, TX 77010-9050

b.State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act

b.Federal Reserve Consumer Help Center P.O. Box 1200 Minneapolis, MN 55480

c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations

c.FDIC Consumer Response Center 1100 Walnut Street, Box #11 Kansas City, MO 64106

d.National Credit Union Administration Office of Consumer Protection (OCP) Division of Consumer Compliance and Outreach (DCCO) 1775 Duke Street Alexandria, VA 22314

Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S. E. Washington, DC 20590

4.Creditors Subject to Surface Transportation Board

Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423

5.Creditors Subject to Packers and Stockyards Act. 1921

6.Small Business Investment Companies

Associate Deputy Administrator for Capital Access United States Small Business Administration 406 Third Street, SW, 8th Floor Washington, DC 20416

Securities and Exchange Commission 100 F St, N.E. Washington, DC 20549

8.Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations

Farm Credit Administration 1501 Farm Credit Drive McLean, VA 22102-5090

9.Retailers, Finance Companies, and All Other Creditors Not Listed Above

FTC Regional Office for region in which the creditor operates or Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 (877)382-4357

jocogov.org/hr @jocogov f/Johnson County Human Resources