RESET                            Department	of	the	Treasury
                                                               Bureau of the Fiscal Service

                      AuthorizAtion                             r    eleAse of nformAtion  i                                                                             for
                                               Fax completed form to:	(855 292-9700)     				

1. TO:  U.S.	Department	of	the	Treasury,	Bureau of the Fiscal Service

   FROM: 

    Name	(include alias and maiden names):                     Mailing	Address	(include street address, p.o. box, suite no., city, state, zip code): 

    Social	Security	Number	or	Employer	Identification	Number:	 Telephone	No.	                                                   Fax	No.

2. I	authorize	the	Fiscal Service,	its	employees,	agents,	and	contractors,	to	disclose	to	the	following

   person: REPRESENTATIVE:

    Name	of	Individual:	                                       Mailing	Address	(include street address, p.o. box, suite no., city, state, zip code): 

    Company	Name	(optional):	                                  Telephone	No.	                                                   Fax	No.

   any	and	all	information	related	to	a	debt	owed	by	me	to	the	United	States	Government,	to	a	State,	or	any	debt	enforced	by	a	State,	
   including	child	support	obligations,	and/or	any	payments	made	or	due	to	me	by	a	Federal	or	State	agency,	and/or	any	tax	return	
   information disclosed to Fiscal Service by the Internal Revenue Service in order to collect tax debt through the levy process under 26  
   U.S.C. § 6331(h), and to conduct tax refund offset under 26 U.S.C. §§ 6402. Tax return information is defined in 26 U.S.C. §
   6103(b). Information includes, but is not limited to, correspondence and other information related to my debt(s) or payment(s), 
   including my tax refund payment(s).
3. Fiscal Service,	its	employees,	agents,	and	contractors,	are	not	required	to	inform	me	of	disclosures	made	under	this	authorization.
4. This	authorization	will	be	valid	for	6	months	from	the	date	of	signing,	unless	sooner	revoked	by	me	in	writing	and	the revocation is
   received and processed by Fiscal Service at this address:  Supervisor, TOP Call Center, P.O. Box 1686, Birmingham, Alabama
   35201-1686.
5. A	photocopy	or	facsimile	copy	of	this	signed	authorization	has	the	same	force	and	effect	as	an	original.
The person named in paragraph 1 must sign below.		If	signed	by	a	corporate	officer,	partner,	guardian,	executor,	receiver,		
administrator,	trustee,	or	party	other	than	the	taxpayer,	I	certify	that	I	have	the	authority	to	execute	this	form.		A separate  
Fiscal Service Form 13 must be provided for each debtor.

Signature of Person Authorizing Disclosure                           Date               

Print Name of Person Authorizing Disclosure                          Print Title of Person Authorizing Disclosure
Privacy Act Statement:	Collection	of	this	information	is	authorized	by	5	U.S.C.	§§	552a,	26	U.S.C.	§§	6331	and	6402,	31	U.S.C.	§§	3716,	3720A	and	7701(c).		
This	information	will	be	used	to	identify	your	debts	submitted	to	the	Treasury	Offset	Program	for	collection	by	Federal	and	State	agencies	and	your	Federal		
payments.		This	information	will	be	disclosed	to	persons	as	authorized	by	you.	Additional	disclosures	of	this	information	may	be	to	Federal	and	State	agencies	
collecting	your	debt	or	issuing	payments	to	you.	The	purpose	of	the	additional	disclosures	will	be	to	verify	the	accuracy	of	the	information	provided	to	Fiscal Service
and	to	assist	such	agencies	in	collecting	your	debt.	Where	the	taxpayer	identification	number	is	your	Social	Security	Number,	collection	of	this	information	is	required	
by	31	U.S.C.	§	7701(c).		If	you	fail	to	furnish	the	information	requested	on	this	form,	including	your	Social	Security	Number,	Fiscal Service	will	not	disclose	to	third	
parties	information	concerning	your	debts	submitted	to	the	Treasury	Offset	Program	for	collection	by	Federal	and	State	agencies	or	your	Federal	payments.				
 FS      FORM 13                                                                                                                                                        
                                                                                                                                DEPARTMENT OF THE TREASURY
    2-61                                                                                                                        BUREAU OF THE FISCAL SERVICE