Form 3170-XXXX TSA Travel Information Form

Travel Information Form
Place responses in the column below
Name:
Address:
City/State/Zip
Date of Birth:
Gender (Female or Male):
Middle Initial or Middle Name (as shown on
traveler’s official Government identification)
If traveler is employed by another Federal
agency, please specify name of agency
Routing List Name and/or Approving
Official’s Name (document approval)
Document Preparer
Is this traveler under contract with agency?
Will they be traveling on behalf of your agency
again?
Direct Deposit Form (Required)

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
the collection of information displays a valid control number assigned by the Office of Management and Budget
(OMB). The OMB Control Number for this form is 3170-0021 and it expires on 7/31/2015. The Bureau will not
disclose any personally identifiable information collected except to the extent that it is required to do so by law and
as provided in the Privacy Act Statement listed below. Additionally, the Bureau will treat the information received
from you consistent with our confidentiality regulations at 12 C.F.R. Part 1070, et seq.
Privacy Act Statement
We ask for the information on this form to make travel arrangements regarding your appointment as an advisory
board member, panel, committee or other group membership or for employment for the United States Government.
The information will be used by and disclosed to employees, contractors, agents and others authorized by the
Consumer Financial Protection Bureau to receive this information to assist in related activities. The information may
also be disclosed:
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to a court, magistrate, or administrative tribunal in the course of a proceeding;
to another federal or state agency or regulatory authority,
to the office of the President; to a member of Congress;
to the public in the form of names, affiliations, and other pertinent biographical information of board or
committee members and;
pursuant to the CFPB’s published Privacy Act system of records notice, CFPB-016, CFPB Advisory
Boards and Committees.

The collection of this information is authorized by Public Law 111-203, Title X, sections 1011, 1012, 1014, codified
at 12 U.S.C. §§ 5491, 5492, 5494.
You are not required to submit your Social Security number or provide any other identifying information. However,
not doing so may prohibit travel arrangements or reimbursement from being processed.