Form Fms 5599 - Authorization To Disclose Information Related To Stored Value Account
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1RESET FORM
U.S. DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SAERVICE
AUTHORIZATION TO DISCLOSE INFORMATION
RELATED TO STORED VALUE ACCOUNT
1. I, _____________________________________________ (the “Cardholder”), authorize the
U.S. Department of the Treasury, Bureau of the Fiscal Service (Fiscal Service) and the U.S.
Department of the Defense (“DoD”) and Fiscal Service 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 _______________________________________________
2. 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, 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, payees; web site usage and other information associated with
my SVC Account.
3. The Disclosing Parties are not required to give me notice of disclosures made under this
authorization.
4. This authorization is valid for one year from the date below, unless I revoke this
authorization sooner by sending written notice by electronic mail to SVC@fms.treas.gov.
Revocation will be effective as of the date the notice is received and processed by Fiscal
Service.
5. A photocopy, facsimile or electronic copy of this signed authorization shall have the same
force and effect as the original.
I certify I am the Cardholder or am legally authorized to sign on behalf of the Cardholder.
___
_______
Signature of Cardholder or Legal Representative
Date
____
Print Name of Cardholder or Legal Representative
FORM
FMS
5599
01-10
EDITION 08-09 IS OBSOLETE
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