Loan For Service Employment Verification Form Page 3
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EXICO
IGHER
DUCATION
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SECTION 3: Consent Waiver
Designation of Authorized Representative
I hereby authorize the following to disclose to the New Mexico Higher Education Department my last
known address, postal and residential, and the name and address of my employer, if known:
(1) United States Internal Revenue Service (2) Bureau of Revenue of any state in which I have filed
tax returns; (3) United States Postal Service; (4) United States Department of Health, Education and
Welfare; (5) United States Social Security Administration; (6) any branch of the United States military
service in which I have served; (7) Department of Motor Vehicle of any state in which I am licensed or
an the registered owner of a vehicle ; and (8) all other institutions, agencies, employers, and
individuals, public or private.
I hereby designate the New Mexico Higher Education Department as my authorized representative
for the purpose of requesting and obtaining such information and I waive on behalf of myself and any
persons who may have an interest in the matter, all provisions of law relating to the confidentiality of
any information so disclosed, specifically including, but limited to, the Federal Privacy Act of 1974, as
amended.
This authorization form is freely given in consideration of funds advanced to me by the above agency.
This authorization shall expire upon completion of my obligation with NMHED.
Borrower
Signature:______________________________________________Date:______________________
Last four digits of your SS#:________________________________
SECTION 4: To be completed by a Notary Public
The foregoing instrument was acknowledge before me this _____________day of __________,
20__ by __________________________________________
My commission expires:_______________________________________
Notary Public Seal __________________________________________
2048 Galisteo Street, Santa Fe, New Mexico 87505
Toll Free Phone: 1-800-279-9777, Fax: 505-476-8454
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