Third Party Authorization Form

THIRD PARTY AUTHORIZATION (TPA) FORM

OMB No. 1845-XXXX
FORM UNDER REVIEW
Exp. Date XX/XX/XXXX

William D. Ford Federal Direct Loan (Direct Loan) Program / Federal Family
Education Loan (FFEL) Program / Federal Perkins Loan (Perkins Loan)
Program / TEACH Grant Program
WARNING: Any person who knowingly makes a false statement or misrepresentation on this form or
on any accompanying document is subject to penalties that may include fines, imprisonment, or both,
TPA
under the U.S. Criminal Code and 20 U.S.C. 1097.
SECTION A: RECIPIENT INFORMATION
Please enter or correct the following information.
Do not enter information about the representative in this
section.
Check this box if any of your information has changed.
SSN
Name
Address
City
State
Zip
Phone (Primary)
Phone (Alternate)
Email
SECTION B: DESIGNATION, CHANGE, OR REVOCATION OF THIRD PARTY
This form may be used to designate an individual or organization to represent you in matters related to your student loans or
grants.
1. Why are you completing this form?
I am designating a third party to represent me or receive information about matters relating to my loans or grants Continue to Item 2.
I am changing the third party that represents me or receives information about matters relating to my loans or grants Continue to Item 2.
I am revoking my previous designation of a third party to represent me or receive information about matters relating to
my loans or grants. Skip to Section C.
2. Is your representative offering its services in exchange for payment?
No.
Yes. As a reminder, you do not need to pay to get help with your loans or grants. The U.S. Department of Education
(the Department) offers those services for free.
3. What do you want the third party to be able to do?
I only want the third party to be able to discuss information about my federal student loans and grants with the
Department.
I want the third party to be able to discuss information about my federal student loans and grants with the Department
and to be able to direct the Department to take any action I could take myself. A third party may not take any action on a
FFEL Program loan not held by the Department, without first contacting the FFEL loan holder for guidance.
4. Please provide contact information for the third party that you are designating.
Individual or

Organization’s Name

Contact’s name if you provided the name of an organization.
(This individual or organization will be referred to as your Representative and must complete Section D)

Recipient Name

Recipient SSN

SECTION C: RECIPIENT'S REQUEST, UNDERSTANDINGS, AUTHORIZATION, AND CERTIFICATION
I request to designate, change, or revoke my authorization of an individual or organization to represent me or receive information
about matters related to my federal student loans or grants that are owned by the Department.
I understand that:
1. The individual or organization that I designate in Section B will have the ability to receive information about my federal
student loans, TEACH Grants, or grant overpayments that is otherwise protected by the Privacy Act of 1974.
2. If I indicated a third party to receive and take action (Section B, Item 3 above) on my federal student loans or federal grants,
the third-party will be able to act on my behalf with the Department, and direct the Department to take specific actions on
my federal student loans that are owned or held by the Department or federal grants; including but not limited to apply for
deferments, forbearances, and/ or repayment plans. I further understand that a third party is not permitted to act on my
behalf and take any action on a FFEL Program student loan(s) not held by the Department without first contacting the FFEL
loan holder for guidance and more information.
3. To verify the third party's identity when making a request for disclosure or providing information by telephone, the third
party may be required to provide my name, Social Security Number, and date of birth.
4. When requesting the disclosure of information, the third party named in Section B must submit information to verify his or
her identity and, if appropriate, the organization for which he or she works.
5. If I am requesting to change or revoke who is an authorized third party, the individual or organization that I previously
designated will no longer be an authorized third party as of the date that the Department receives my request.
6. If I am requesting to revoke the third-party authorization, I may do so in any oral or written communication to the
Department.
7. An authorized third party may also revoke my designation in any oral or written communication to the Department; and
8. My designation, change, or revocation will be effective on the date that the Department receives and (if written) processes
my communication.
I authorize the Department and its agents to release to, and discuss with, the individual or organization named in Section B any
records held by the Department regarding my federal student loan or TEACH Grant service obligation(s) and to send
correspondence related to my discharge request (if applicable) to that individual or organization.
I certify that all of the information I have provided on this form and in any accompanying documentation is true, complete, and
correct to the best of my knowledge and belief.

Recipient's Signature

Date

Recipient Name

Recipient SSN

SECTION D: REPRESENTATIVE'S UNDERSTANDINGS AND AFFIRMATION
As the individual or organization designated as an authorized third-party representative in Section B of the recipient identified in
Section A, please complete the appropriate information below and affirm your intent to adhere to the terms of this request by
marking the required boxes and signing this form.
1. Are you completing this form as an individual or an organization representing the recipient?
Individual – continue to item 2a.
Organization – continue to item 2b.
2a.

2b.

Name___________________________________________
Address_________________________________________
City_______________________State______Zip_________
Phone (Primary)___________________________________
Phone (Alternate)__________________________________
Email____________________________________________

Organization Name________________________________
Tax ID Number___________________________________
CEO Name_______________________________________
Address_________________________________________
City_______________________State______Zip_________
Phone (Primary)__________________________________
Phone (Alternate)_________________________________
Email___________________________________________
Website_________________________________________
Contact Name____________________________________

3. Required affirmations for all representatives:
By checking this box, I, the representative, affirm that I will adhere and comply with the code of conduct (Section F,
Important Notices), information security standards, and the terms of service regarding the use and access of data
pertaining to the federal loan and/or grant recipient above pursuant to the September 10, 2021, Federal Register Notice).
By checking this box, I, the representative, affirm I have not and will not ask the individual identified in Section A
for their FSA ID or username and password, and will not seek to log into any loan servicer or Federal Student Aid system
using their credentials. I, the representative, acknowledge and understand the use of an access device ( 18 U.S.C.
§1029(e)(1) U.S.C.) issued to another person or obtained by fraud or false statement to access Department information
technology systems for purposes of obtaining commercial advantage or private financial gain, or in furtherance of any
criminal or tortious act in violation of the Constitution or laws of the United States or of any State shall face criminal
penalties pursuant to Section 490 of the Higher Education Act of 1965 (20 U.S.C. 1097), as amended.
By signing below, I, the representative, declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct.

Representative's Signature

Date

SECTION E: WHERE TO SEND THE COMPLETED FORM

SECTION F: IMPORTANT NOTICES
Privacy Act Notice. The Privacy Act of 1974 (5 U.S.C. 552a)
requires that the following notice be provided to you: The
authorities for collecting the requested information from and
about you are §421 et seq., §451 et seq., §461, or §420L of the
Higher Education Act of 1965, as amended (20 U.S.C. 1071 et
seq., 20 U.S.C. 1087a et seq., 20 U.S.C. 1087aa et seq., or 20
U.S.C. 1070g et seq.) and the authorities for collecting and
using your Social Security Number (SSN) are §§428B(f) and
484(a)(4) of the HEA (20 U.S.C. 1078-2(f) and 1091(a)(4)) and 31
U.S.C. 7701(b). Participating in the Direct Loan, FFEL, Perkins
Loan, or TEACH Grant 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, FFEL, Federal Perkins Loan
or TEACH Grant Programs; to permit the servicing of your loans;
and, if it becomes necessary, to locate you and to collect and
report on your loans if your loans become delinquent or enter
into default status. 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. A list of the
Department’s system of record notice issuances is located at
https://www2.ed.gov/notices/ed-pia.html. 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 loans, to enforce the terms of the loans, 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
statuses, 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 such collection displays a valid
OMB control number. The valid OMB control number for this
information collection is 1845-0XXX. Public reporting burden for
this collection of information is estimated to average 30 minutes
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, please refer to
the contact information provided in Section E.

Code of Conduct Notice. The Code of Conduct identifies the
acceptable rules of behavior for accessing the Department’s
information systems. Upon accessing the Department’s
information systems, all users will receive a notification
warning banner similar to the following that requires them to
acknowledge and agree to the Code of Conduct prior to being
allowed further access:
You are accessing a U.S. Federal Government computer
system intended to be solely accessed by individual users
expressly authorized to access the system by the U.S.
Department of Education. Usage may be monitored, recorded,
and/or subject to audit. For security purposes, and in order to
ensure that the system remains available to all expressly
authorized users, the U.S. Department of Education monitors
the system to identify unauthorized users. Anyone using this
system expressly consents to such monitoring and recording.
Unauthorized use of this information system is prohibited and
subject to criminal and civil penalties. Except as expressly
authorized by the U.S. Department of Education, unauthorized
attempts to access, obtain, upload, modify, change, and/or
delete information on this system are strictly prohibited and
are subject to criminal prosecution under 18 U.S.C. 1030, and
other applicable statutes, which may result in fines and
imprisonment. This system may contain Personally Identifiable
Information (PII), as defined by the Privacy Act of 1974, or
other Controlled Unclassified Information as defined by 32 CFR
2002.
For purposes of this system, unauthorized access
includes, but is not limited to— (a) Any access by an employee
or agent of a commercial entity, or other third party, who is not
the individual user, for purposes of commercial advantage or
private financial gain (regardless of whether the commercial
entity or third party is providing a service to an authorized user
of the system); and (b) Any access in furtherance of any
criminal or tortious act in violation of the Constitution or laws
of the United States or any State. If system monitoring reveals
information indicating possible criminal activity, such evidence
may be provided to law enforcement personnel. These Rules of
Behavior identify responsibilities and expectations for all
individuals accessing Federal Student Aid (FSA) systems. By
accepting, you confirm that you have reviewed, acknowledge,
and agree to the following Rules of Behavior: (a) You must
protect all of the Department’s information systems, including
the Department’s data and information in your possession,
from access by, or disclosure to, unauthorized individuals or
entities. (b) Your User ID, password, and other credentials are
unique and only assigned to the specified authorized user. (1)
Your User ID, password, and other credentials serve as an
electronic signature for signing fiduciary documents committing
you to financial obligations. (2) Your User ID, password, and
other credentials are for official Department business only. (c)
You must never give your User ID, password, or other
credentials to another person, including your supervisor(s).
Any information retrieved from the Department’s information
systems may be shared only with individuals expressly

authorized to receive this information. (d) You must access only
systems, networks, data, control information, and software for
which you have been authorized by the U.S. Department of
Education. (e) If you are a third party representing an authorized
user under paragraph (b) of the “Acceptable Use of Systems,”
you must be issued your own unique User ID, password, or
credentials; at no time is a third party authorized to use another
individual’s unique User ID, password, or credentials. A user
may not authorize a third party to use their User ID, password,
or credentials, including through a power of attorney. (f) You are
individually responsible for ensuring that data/information
obtained from the Department’s information systems is not used
improperly. A legitimate reason must be present to view
data/information contained within the Department’s
information systems. (g) You must change your password
immediately and notify the appropriate security personnel if
your password is compromised, or someone else knows your
password. (h) You must properly encrypt (or password protect)
all electronic files when transmitting data via email. Passwords
must be sent separately (not in the same transmission or
transmission channel). (i) All paper documents containing PII or
Controlled Unclassified Information must be labeled and stored
in a secure environment, to which only authorized personnel
have access. (j) You must inform or contact the organization that
granted initial access when access to an FSA system is no longer
required or access changes because of changes in job
responsibilities or termination of employment. (k) You must
remain current on all required training, including security
training (at least annually). (l) You must not download or store
the Department’s information systems information or data on
unsecure/public computers or portable devices. (m) If you have
Title IV loans, they must be in good standing. If you have a loan
that goes into default, your access to the Department’s
information systems to administer Title IV Programs under the
HEA will be revoked. Access to manage and view your own Title
IV loans and financial aid history through the Department’s
information systems and/or your federal loan servicer as a
borrower will not be revoked.