FS Form 5752 Authorization to Disclose Information Related to Stored

FOR OFFICE USE ONLY:
Cardholder Name

Cardholder No.

FS FORM 5752
Department of the Treasury
Bureau of the Fiscal Service
(Revised September 2016)

AUTHORIZATION TO DISCLOSE INFORMATION
RELATED TO STORED VALUE ACCOUNT

OMB No. 1530-0013
Expires September 2019

IMPORTANT: You should be aware that the making of any false, fictitious, or fraudulent claim or statement to the United States
is a crime that is punishable by fine and/or imprisonment.
PRINT IN INK OR TYPE ALL INFORMATION

1. AUTHORITY
A. I, ____________________________________________ (the “Cardholder”), authorize the U.S. Department of the
Treasury, Bureau of the Fiscal Service (“Fiscal Service”) and the U.S. Department of Defense (“DoD”) and Fiscal
Service’s and DoD’s subordinate departments or agencies, along with their employees, agents, and contractors (the
“Disclosing Parties”) to disclose any and all information related to my EagleCash, Navy Cash, Marine Cash, or
EZpay Stored Value Card account(s) (“SVC Account”) to the following:
Military and civilian law enforcement agencies and prosecutors
Other _________________________________________________
B. Information related to my SVC Account includes, but is not limited to, my Stored Value Card number and associated
account number; my name, addresses, and other contact information; my social security number, other identifying
numbers and types of identification, date of birth, and other demographic information about me; information about
bank account(s), including routing and account numbers, which I have linked to my SVC Account or from which I
have transferred funds to or from my SVC Account; my balance and transaction history, including the amount, date,
time, tracking numbers, location, merchants, and payees; website usage; and other information associated with my
SVC Account.
C. The Disclosing Parties are not required to give me notice of disclosures made under this authorization.
D. A photocopy, facsimile, or electronic copy of this signed authorization shall have the same force and effect as the
original.
2. TERM AND DURABILITY
This authorization to disclose information is valid for one year from the date indicated below, unless it is revoked sooner
by sending written notice by e-mail to [email protected]. Revocation will be effective as of the date the notice is
received and processed by the Fiscal Service.
3. SIGNATURE
I certify I am the Cardholder or am legally authorized to sign on behalf of the Cardholder.

Sign Here:

_____________________________________________
Signature of Cardholder or Legal Representative

_____________________________________________
Print Name of Cardholder or Legal Representative

____________________________
Date

____________________________
E-Mail Address (Optional)

NOTICE UNDER PRIVACY ACT AND PAPERWORK REDUCTION ACT
AUTHORITY: 5 U.S.C. 552a; 31 CFR 210; and E.O. 9397.
PRINCIPAL PURPOSE(S): To obtain authorization to disclose information considered private under Treasury regulations and Privacy Act.
ROUTINE USE(S): The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act of 1974, as
amended. It may be disclosed outside of the U.S. Department of the Treasury to its Fiscal and Financial Agents and their contractors involved in
providing SVC services, or to the Department of Defense (DoD) for the purpose of administering the Treasury SVC programs. In addition, other
Federal, State, or local government agencies that have identified a need to know may obtain this information for the purpose(s) as identified by the
Bureau of the Fiscal Service (Fiscal Service) Routine Uses as published in the Federal Register.
DISCLOSURE: Furnishing the information is voluntary; however, failure to furnish requested information may significantly delay or prevent disclosure of
the information you have requested.
We estimate it will take about 1 minute to complete this form. However, you are not required to provide the information requested unless a valid OMB
control number is displayed on the form. Any comments or suggestions regarding this form should be sent to the U.S. Department of the Treasury,
Bureau of the Fiscal Service, 401 14th Street SW, Washington DC 20227.

FS Form 5752