RETURN CUSTOMER CONSENT FORM BY FAX TO 888-938-4715 OR EMAIL TO GLDC@ATT.COM FOR PROCESSING.


AT&T CUSTOMER AUTHORIZATION FOR RELEASE OF RECORDS


Pursuant to 18 U.S.C. 2703(c) and 47 U.S.C. 222, I,                                  , herby authorize (Name of Account Holder)


AT&T to release my records to (check one of the boxes below):

image Myself (if selected ONLY complete sections 1 & 2)

image Third Party Agency, e.g. law enforcement or attorney (if selected complete sections 1 – 4 below)


Section 1: Customer Information


Account Holder (Print Name):                                            Last 4 of SS# (if applicable): XXX-XX                                      Address of account holder:                                              Contact number of account holder:                                           Cellular/Landline number of records being provided:                                  Start date of records:                                                   End date of records:                                 


BILLING: A processing fee of $70.00 will be billed for all customer consent requests. We ask that you include payment with the returned form. This form must be completed by the account holder. If the information provided does not match our records, the processing fee of $70.00 will still apply and records will not be provided. As a reminder, AT&T postpaid records can be found online for the previous 16 months. www.att.com

By signing below you agree with the charges associated

Signature of Customer of Record (Account Holder):                      

Section 2: Type of Records Requested

Check boxes that apply:

image Outgoing Call records image Outgoing Text records

image Statements/invoices pertaining to my telephone service for month and year. (Ex. 01/2019 – 03/2019) image Other                                  


Section 3: Agency Information

Name of agency to receive information:                                         Name of person to receive information:                                         Address of Agency:                                                    Reference or case number (if applicable):                                        Contact number of person:                                                Fax number (if available):                                                Email address (if available):                               

Preferred method to send records to agency (check one): image Mail imageFax imageEmail


Section 4: Notary Certificate

STATE OF                          COUNTY OF             

The foregoing Customer Authorization was sworn to and subscribed before me this                by    

(Customer Name) (date)

who is personally known to me or has produced a                                  as identification.

(form of photo identification produced)

RETURN CUSTOMER CONSENT FORM BY FAX TO 888-938-4715 OR EMAIL TO GLDC@ATT.COM FOR PROCESSING.


CREDIT CARD PAYMENT FORM


Invoice Information:


Matter ID (If provided):               


Date:                 


Amount: $              


Customer Information:


Name as it Appears on Credit Card:                       


Phone Number:                               


Credit Card Number:                             


Expiration Date:               

image


Total Amount To Be Authorized: $                


TRANSACTION WILL APPEAR AS “AT&T POS” ON STATEMENT.


CREDIT CARD RECEIPT REQUESTED VIA:


                               OR                        EMAIL ADDRESS FAX NUMBER