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).
Fiscal Service, its employees, agents, and contractors, are not required to inform me of disclosures made under this authorization.
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
5. A photocopy or facsimile copy of this signed authorization has the same force and eﬀect as an original.
e 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
DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE
Bureau of the Fiscal Service
AuthorizAtion for releAse of informAtion
Fax completed form to: (855) 292-9700
TO: U.S. Department of the Treasury, Bureau of the Fiscal Service
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.
I authorize the Fiscal Service, its employees, agents, and contractors, to disclose to the following
Name of Individual: Mailing Address (include street address, p.o. box, suite no., city, state, zip code):
Company Name (optional): Telephone No. Fax No.
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).
n 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.