Complete this application and return it to FedLoan Servicing to allow the person(s) stated below to have access to all
data contained in your FedLoan Servicing-administered loan or TEACH Grant record for the purposes of assisting
you in resolving FedLoan Servicing related issues.
Authorization for Release of Information
Section 1: Borrower/Recipient Identification
Name:
Account Number
Section 2: Third Party Identification
Name
Relationship
Street Address:
City
State
Zip Code
Telephone
Party 2:
Name Relationship
Street Address:
City
State
Zip Code
Telephone
I hereby authorize FedLoan Servicing to release information about my account, including personally identifying information and my
relationship with FedLoan Servicing to the individual(s) listed above. I understand and agree that by authorizing FedLoan Servicing to
release any and all information to the individual(s) named and listed above. I assume full responsibility for the named individual(s) having
access to any information maintained by FedLoan Servicing relating to me. It is my responsibility to revoke my authorization(s) if at
any time I no longer wish to authorize FedLoan Servicing to release information about me to the individual(s) listed above. I
acknowledge that this authorization allows the named individual(s) to obtain any/all data and information contained in my
FedLoan Servicing-administered student aid record. I hereby expressly agree that FedLoan Servicing shall not be responsible for any
damages in any form arising that I may incur related to my authorization(s) of FedLoan Servicing to release information to the individual(s)
listed above. Completion of this form also provides permission to accept information concerning to my address and/or telephone number
from the individual(s) listed above. This authorization does not release me from my obligation to make payments on my loan(s).
Borrower/Recipient Signature
Date
Section 3: Borrower/Recipient Authorization and Signature
Party 1:
Send Completed form to: FedLoan Servicing
P.O. Box 69184
Harrisburg, PA 17106-9184
Or Fax to: 717-720-1628
Records Code:
Form Code:
Version Date:
BF10Q - XBCR
FD - TPRM
01/01/2019
