Revocation-of-Consent_en_2023-08-02

Draft 2023-08-02 Do not submit

Revocation of Consent
to Use Federal Tax Information
OMB No. 1845-XXXX

Expiration Date: xx/xx/xxxx

You can revoke your approval and consent for the disclosure and use of your federal tax information (FTI).
To revoke consent, complete and submit this form or go to StudentAid.gov and revoke your consent online.
For help in filling out this form, call 1-800-4-FED-AID (1-800-433-3243).
You previously approved and consented to the U.S. Department of Education disclosing your Social Security number, last
name, and date of birth to the U.S. Department of the Treasury for the disclosure of your federal tax information (FTI) with
Department of Education officials and contractors (as defined in 26 U.S.C. § 6103(l)(13)) for the purpose of determining
eligibility for, or repayment obligations under, income-driven repayment (IDR) plans (income-contingent or income-based
repayment plans), as authorized under Part D of Title IV of the Higher Education Act of 1965, as amended (HEA).

Privacy Act Statement
Authority: Title IV of the Higher Education Act of 1965, as amended (HEA) (20
U.S.C. 1070 et seq.), authorizes the Department of Education (Department)
to ask the questions set forth in this Revocation of Consent to Use Federal
Tax Information form, including collecting Social Security numbers (SSNs)
from the aid recipient, and, where necessary, the spouse of a married aid
recipient. The collection of the SSNs is also authorized by Executive Order
9397, as amended by Executive Order 13478 (November 18, 2008).
Purpose: We use the information provided on this form to process the
revocation of approval and consent for the disclosure and use of federal
tax information (FTI) received from the Internal Revenue Service (IRS)
for purposes of determining eligibility for, or repayment obligations under,
income-driven repayment (IDR) plans (income-contingent or income-based
repayment plans) as authorized under Part D of Title IV of the HEA. An
aid recipient’s SSN, and, where necessary, that of the spouse of a married
aid recipient, is used to verify identity and retrieve records to process this
form. We also may verify the accuracy of the information provided to the
Department.
Routine Uses: The information provided on this form will only be disclosed
outside of the Department with prior written consent or as otherwise allowed
by the Privacy Act of 1974, as amended (Privacy Act) (5 U.S.C. 552a).
The Privacy Act’s requirement for prior written consent has an exception
for “routine uses” that the Department publishes in our System of Records
Notices (SORNs). The Department may disclose, without consent, the
information provided on this form pursuant to the routine uses identified in the
“Person Authentication Servicer (PAS)” (18-11-12) SORN, which is available
on the Department’s “Privacy Act System of Record Notice Issuances
(SORN)” webpage located at https://www2.ed.gov/notices/ed-pia.html.
These routine uses include the following:
• To validate the personally identifiable information (PII) entered by the
current, former, or prospective aid applicant or aid recipient (or their
third-party preparer) or endorser, whom records indicate is applying for,
has applied for, has endorsed, or has received an HEA Title IV loan
and/or grant, or the PII entered by a participant of such an application
(including the spouse of an independent aid applicant or recipient or
the parent[s] of a dependent aid applicant or recipient), disclosures may
be made to: guaranty agencies; educational and financial institutions;
federal loan (including Federal Perkins Loan) servicers; federal, state,

local, or tribal agencies; private parties such as relatives, business
and personal associates, and present and former employers; creditors;
consumer reporting agencies; adjudicative bodies; and the individual
whom the records identify as the endorser or the party obligated to
repay the debt.
• To determine program eligibility and benefits, disclosures may be made
to: guaranty agencies; educational and financial institutions; federal
loan (including Federal Perkins Loan) servicers; federal, state, local, or
tribal agencies; private parties such as relatives, business and personal
associates, and present and former employers; creditors; consumer
reporting agencies; and adjudicative bodies.
• To permit the Department to disclose information on aid applicants
and recipients to the IRS for the IRS to disclose FTI under subsection
494(a) of the HEA (20 U.S.C. 1098h(a)) and section 6103(l)(13)(A) and
(C) of the Internal Revenue Code (IRC) to the Department as part of
a matching program to determine their eligibility under Title IV of the
HEA and to permit the Department to redisclose the FTI of individuals
pursuant to section 6103(l)(13)(D)(iv) of the IRC and the revocation of
such consent/affirmative approval for IDR, disclosures may be made to
federal loan servicers.
Effects of Not Providing Information: Providing information on this
form, including an aid recipient’s SSN, is voluntary; however, if not
enough information is provided to process a revocation of consent form,
the request may be delayed or denied.
The Paperwork Reduction Act of 1995: According to the Paperwork
Reduction Act of 1995, no persons are required to respond to a collection
of information unless such collection displays a valid Office of Management
and Budget (OMB) control number. The valid OMB control number for
this information collection is 1845-NEW. Public reporting burden for this
collection of information is estimated to average one and a half hours
per response, including time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. The obligation to respond to
this collection is voluntary. If you have comments or concerns regarding
the status of your individual submission of this form, write directly to the
Federal Student Aid Information Center, P.O. Box 84, Washington, DC
20044. (Note: Do not return the completed form to this address.)

Go to page 2 and complete the revocation form.

Revocation of Consent

For purposes of repayment obligations under the HEA, your FTI (and, if you are married, your spouse’s FTI) is used solely to
determine your payment amount for a qualifying IDR plan now or in the future. If you revoke your approval and consent, the
Department of Education will be unable to determine your eligibility for, or repayment obligations under, such plans now or in
the future, which will require that you, and your spouse (if applicable), annually provide alternative documentation of income
to remain eligible for an IDR plan.

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Draft 2023-08-02 Do not submit

Revocation of Consent
to Use Federal Tax Information

For help in filling out this form, call 1-800-4-FED-AID (1-800-433-3243).

Complete the Form
You may fill the answer fields electronically and then print the form, or print the form first and complete it by hand.
If you complete the form by hand, use dark ink and print clearly using
BLOCK CAPITAL letters. Only skip a box between words; for multi-line
responses, wrap any incomplete words onto next line:

1

4

1

6

P L U M

S

A P T

4

T R E E T

Continue on next line.

Last name
Date of birth
/

Social Security number (SSN)
–

/

–

MM / DD / YYYY

Permanent mailing address
Continue on next line.

Include apt. number.

City
ZIP code

Country
–

State

Common country codes: US (United States), CA (Canada), and MX (Mexico). For U.S.
territories, use their state code as their country code (for example, PR for Puerto Rico).

Revocation of Consent

First name

Sign the Form
By completing and signing this form, you understand and agree that revoking your approval and consent will prohibit the
U.S. Department of Education from using your personally identifiable information (PII) to request the U.S. Department
of the Treasury to disclose your federal tax information (FTI) for the purposes of determining your eligibility for, or
repayment obligations under, income-driven repayment (IDR) plans (income-contingent or income-based repayment
plans) outlined on page 1.
Signature

Date signed
/

/

MM / DD / YYYY

Mail the Form
Make a copy of this form for your records and then mail the original of page 2 to:

Federal Student Aid Programs, P.O. Box 70206, London, KY 40742-0206
After your Revocation of Consent to Use Federal Tax Information is processed, you will be notified by mail. If you would like to
check the processing status of your revocation of consent, go to StudentAid.gov or call 1-800-433-3243.

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