Checklist 2.3: Denial of Deposit Account
Applicant’s Name
Method
Rec.
Date
Rec.
Date
Action
Type
Action
Date
Notice
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Use the following section for all adverse action notices to consumers for denials of
Risk
Rating deposit accounts.
If adverse action against the consumer was based in whole or part on information in a
“consumer report,” did the institution:

Inform consumer of that fact orally, electronically, or in writing;
15 USC 1681m(a)(1)

Include name, address, and phone number of consumer reporting agency;
15 USC 1681m(a)(3)(A)

Include a statement that agency doesn’t know reasons for denial and can’t provide
them; 15 USC 1681m(a)(3)(B)

Include a statement of right to a free copy of consumer report; and
15 USC 1681m(a)(4)(A)

Include a statement of right to dispute information?
15 USC 1681m(a)(4)(B)
Provide to the consumer written or electronic disclosure:
1681m(a) (2)

Of a numerical credit score (as defined in 1681g(f)(2)(A)) used by such person in
taking any adverse action based in whole or in part on any information in a
consumer report; 1681m(a) (2) (A)

The information set forth in 1681g(f)(1) (B) through (E), which is:
1681m(a) (2) (B)
 The range of possible credit scores under the model used;
 All of the key factors that adversely affected the credit score of the consumer
in the model used, not to exceed four;
 The date on which the credit score was created; and
 The name of the person or entity that provided the credit score or credit file
upon which the credit score was created.
Comments:
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