Consent to Disclosure of Tax Information - LC

OMB No. 1845-0017 Form Approved Exp. Date xx/xx/xxxx		William D. Ford Federal Direct Loan Program Income Contingent Repayment Plan & Income-Based Repayment Plan Consent to Disclosure of Tax Information
I (We) authorize the Internal Revenue Service (IRS) to disclose certain tax return information (for the tax years listed below) which includes my (our) name(s), address(es), Social Security Number(s), filing status, tax year, and Adjusted Gross Income(s). This information will be disclosed to the U.S. Department of Education (ED) and the William D. Ford Federal Direct Loan (Direct Loan) Program contractors and subcontractors for the sole purpose of determining the appropriate income contingent repayment (ICR) amount, or determining eligibility for income-based repayment (IBR) and the appropriate IBR amount on the Direct Loan Program loan(s) that may be repaid under the ICR or IBR Plan. ED’s Direct Loan Program contractors and subcontractors may change. You may obtain the names of the current Direct Loan Program contractors and subcontractors by writing to ED at the address shown at the bottom of this page.
Request for Tax Years: xxxx, xxxx, xxxx, xxxx, and xxxx. Read the instructions on the back of this form before completing the items below. Items 1-3: If you are repaying or want to repay your loan(s) under the Income Contingent Repayment Plan or the Income-Based Repayment Plan, you must complete Items 1-3 below:
	(1) Borrower’s (Taxpayer’s) Name Printed as it appears on your tax returns				(2) Borrower’s (Taxpayer’s) Social Security Number
					_____-_____-________(MM-DD-YYYY)
	(3) Borrower’s (Taxpayer’s) Signature Signature is valid for 60 days – see instructions on the back of the form.				Date of borrower's signature
	Items 4-6: Your spouse must complete Items 4-6 if: You are repaying under the Income Contingent Repayment Plan and you are married, OR You are repaying under the Income-Based Repayment Plan and you and your spouse file a joint federal income tax return.
	(4) Spouse’s (Taxpayer’s) Name Printed as it appears on your tax returns				(5) Spouse’s (Taxpayer’s) Social Security Number
					_____-_____-________(MM-DD-YYYY)
	(6) Spouse’s (Taxpayer’s) Signature Signature is valid for 60 days – see instructions on the back of the form.				Date of spouse's signature
	Return this form to:		U.S. Department of Education Consolidation Department P.O. Box 242800 Louisville, KY 40224-2800

William D. Ford Federal Direct Loan Program

Income Contingent Repayment Plan & Income-Based Repayment Plan – Consent to Disclosure of Tax Information

Borrower Instructions: Please complete this form using the following instructions. To be considered for the Income Contingent Repayment Plan or the Income-Based Repayment Plan, you must complete Items 1-3 for the Consent to Disclosure of Tax Information on the front of this form:

Item 1. Print (or type) your name as it appears on your tax returns.

Item 2. Print (or type) your Social Security Number.

Item 3. Sign and date the form in blue or black ink only. Report the date as month-day-year (MM-DD-YYYY).

Items 4-6 must be completed only if:

• You are repaying under the Income Contingent Repayment Plan and you are married (even if you file separate federal income tax returns), OR

• You are repaying under the Income-Based Repayment Plan and you and your spouse file a joint federal income tax return.

(Do not complete Items 4-6 if you are repaying under the Income-Based Repayment Plan and you and your spouse file separate federal income tax returns.)

Item 4. Print (or type) your spouse’s name as it appears on tax returns.

Item 5. Print (or type) your spouse’s Social Security Number.

Item 6. Have your spouse sign and date the form in blue or black ink only. Report the date as month-day-year (MM-DD-YYYY).

Make a copy of the completed form for your records. Send the original form to the U.S. Department of Education (ED) at the address shown on the front. DO NOT SEND THIS FORM TO THE INTERNAL REVENUE SERVICE (IRS). Once your application to participate in the Income Contingent Repayment Plan or the Income-Based Repayment Plan has been approved, ED will forward this form to the IRS. Because the IRS will not accept this form if more than 60 days have passed since you and/or your spouse signed the form, you must return the completed form to ED promptly.

Request to Revoke Tax Information Authorization: You and/or your spouse may revoke the Consent to Disclosure of Tax Information at any time. To revoke consent, send a copy of this completed form with the word “REVOKE” across the top directly to the revocation address given below. The revocation must be signed by the taxpayer(s) who signed the original Consent to Disclosure of Tax Information. If you and/or your spouse do not have a copy of the original form, a statement of revocation is acceptable. The statement must indicate that the authority to disclose tax information to the Direct Loan Program is revoked, and must be signed by the taxpayer(s) who signed the original authorization form.

NOTE: If you and/or your spouse revoke(s) the Consent to Disclosure of Tax Information, you and/or your spouse become(s) ineligible for income contingent or income-based repayment, and you and/or your spouse must contact the Direct Loan Servicing Center to select another repayment option. If you and/or your spouse fail(s) to contact the Direct Loan Servicing Center, ED will assign you and/or your spouse to the Standard Repayment Plan.

Revocation Address: Direct Loan Servicing Center

P.O. Box 5609

Greenville, TX 75403-5609

PRIVACY ACT NOTICE

The Privacy Act of 1974 (5 U.S.C. 552a) requires that the following notice be provided to you:

The authority for collecting the requested information from and about you is §451 et seq. of the Higher Education Act (HEA) of 1965, as amended (20 U.S.C. 1087a et seq.) and the authorities for collecting and using your Social Security Number (SSN) are §484(a)(4) of the HEA (20 U.S.C. 1091(a)(4)) and 31 U.S.C. 7701(b). Participating in the William D. Ford Federal Direct Loan (Direct Loan) Program and giving us your SSN are voluntary, but you must provide the requested information, including your SSN, to participate.

The principal purposes for collecting the information on this form, including your SSN, are to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan (such as a deferment, forbearance, discharge, or forgiveness) under the Direct Loan Program, to permit the servicing of your loan(s), and, if it becomes necessary, to locate you and to collect and report on your loan(s) if your loan(s) become delinquent or in default. We also use your SSN as an account identifier and to permit you to access your account information electronically.

The information in your file may be disclosed, on a case-by-case basis or under a computer-matching program, to third parties as authorized under routine uses in the appropriate systems of records notices. The routine uses of this information include, but are not limited to, its disclosure to federal, state, or local agencies, to private parties such as relatives, present and former employers, business and personal associates, to consumer reporting agencies, to financial and educational institutions, and to guaranty agencies in order to verify your identity, to determine your eligibility to receive a loan or a benefit on a loan, to permit the servicing or collection of your loan(s), to enforce the terms of the loan(s), to investigate possible fraud and to verify compliance with federal student financial aid program regulations, or to locate you if you become delinquent in your loan payments or if you default. To provide default rate calculations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to state agencies. To provide financial aid history information, disclosures may be made to educational institutions. To assist program administrators with tracking refunds and cancellations, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal or state agencies. To provide a standardized method for educational institutions to efficiently submit student enrollment status, disclosures may be made to guaranty agencies or to financial and educational institutions. To counsel you in repayment efforts, disclosures may be made to guaranty agencies, to financial and educational institutions, or to federal, state, or local agencies.

In the event of litigation, we may send records to the Department of Justice, a court, adjudicative body, counsel, party, or witness if the disclosure is relevant and necessary to the litigation. If this information, either alone or with other information, indicates a potential violation of law, we may send it to the appropriate authority for action. We may send information to members of Congress if you ask them to help you with federal student aid questions. In circumstances involving employment complaints, grievances, or disciplinary actions, we may disclose relevant records to adjudicate or investigate the issues. If provided for by a collective bargaining agreement, we may disclose records to a labor organization recognized under 5 U.S.C. Chapter 71. Disclosures may be made to our contractors for the purpose of performing any programmatic function that requires disclosure of records. Before making any such disclosure, we will require the contractor to maintain Privacy Act safeguards. Disclosures may also be made to qualified researchers under Privacy Act safeguards.

Paperwork Reduction Notice: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 1845-0017. The time required to complete this information collection is estimated to average 0.2 hours (12 minutes) per response, including the time to review instructions, search existing data resources, gather and maintain the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4537. Do not send the completed form to this address.

If you have questions about the status of your individual submission of this form, contact the Consolidation Department at the following address:

U.S. Department of Education

Consolidation Department

P.O Box 242800

Louisville, KY 40224-2800