RESET

                                               Department	of	the	Treasury
                                               Financial Management Service

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

1. TO:  U.S.	Department	of	the	Treasury,	Financial	Management	Service	(FMS)

   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	FMS,	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	infor-
   mation	disclosed	to	FMS	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. FMS,	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	FMS	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  
FMS 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	FMS	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,	FMS	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.				
   FORM                                                                                                    DEPARTMENT OF THE TREASURY
FMS      9-08 13                                                                                           FINANCIAL MANAGEMENT SERVICE