U.S. Department of Justice

                                                                        Office of Justice Programs

                                                                        Bureau of Justice Assistance
                                     
                                                                        Washington, D.C. 20531

                   Denial of Federal Benefits Verification Request Form
                         
Request From (Please Print):

     Agency/Company:
______________________________________________________________________________ 
                      
                              
     Name:          
______________________________________________________________________________ 

                                                                      
     
     Address:       
______________________________________________________________________________

     Phone Number:   (_______)_______-_________Ext. ______ Fax Number: 
(_______)_______-__________
                                                            
Verification On (Please Print):                                                 
                                                  
     Name:          
______________________________________________________________________________ 
                                                     
               
                                                  
     Birth Date:     ______/_______/______ Social Security
Number:_________-________-______________
                                                  
                                                  
     Cause and Treatment Code(CT-Code 1): 
________________________________________________________
                                                  
Federal Benefit    
______________________________________________________________________________
_
Applied For         
and Other          
______________________________________________________________________________
_
Information:
               
The undersigned hereby certifies that the above data is true, and is authorized by said individual,
to
make such a request on his/her behalf.  The undersigned also certifies that said individual's name
was
published in the GSA "List of Parties Excluded from Federal Procurement and Nonprocurement
Programs,"
with a Cause and Treatment Code of AA, PP, BB, or QQ.  I have read, and understand the
meaning
of these codes, and that this inquiry meets the requirements of the code displayed for said
individual,
and will be used for this specific purpose only.


                    __________________________________________________ 
___________________________
                                      Signature                                    Date

For Denial of Federal Benefits Use Only:

     Date Received:  _________/_________/_________       Processor:
_______________________________
     
     Match Found:    (        )   Yes   (        )    No    
                    

                        The Denial of Federal Benefits Clearinghouse
          Bureau of Justice Assistance, 810 7th Street, N.W. Washington, DC 20531
                        Fax: 301-860-1837        Phone: 301-809-4904  
                    Web Site: http://www.ojp.usdoj.gov/BJA/grant/dfb.html