Form Version 12/12/22 Revision 6

Creditor Agency Profile Cover Sheet

Agency Code: Agency Name: 

Bureau Code: Bureau Name: 

Office Code: Office Name: 

Program Code: Program Name: 

Update Type 

Point of Contacts 

 Other

By signing below, I certify that I have delegated authority to execute this Cross-Servicing Agency Profile on behalf of the head of the Creditor Agency.

Agency

Primary

Alternate

TROR

Address

Bureau

Primary

Alternate

Address

Office

Primary

Alternate

Address

Program

Main IPAC E-File 1099-C Dispute AWG

 Primary Primary Primary Primary Primary Primary

Alternate Alternate Alternate Alternate Alternate Alternate

Notes/Specific Instructions: 

Tools

 PCA AWG CBR 1099C DOJ TOP

 Compromise Authority Interest Accrual Penalty Accrual

______________________________

Digital Signature (upon profile completion)

__________________________________

Printed Name

______________________________

Date

____________________________________

Phone Number or Email Address
Form Version 12/12/22 Revision 6 1

Agency Information

Agency Name 

Address 

Address 

City 

State 

Zip 

CFO Agency Yes No

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 2

TROR Contact Information 

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

For Fiscal Service Use Only:

Agency Code:

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 3

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

For Fiscal Service Use Only:

Bureau Code:

 Cross-Servicing Agency Profile

Bureau Information

Bureau Name 

Address 

Address 

City 

State 

Zip 
Form Version 12/12/22 Revision 6 4

Office Information 

Office Name 

Address 

Address 

City

State 

Zip

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

For Fiscal Service Use Only:

Office Code:

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 5

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

For Fiscal Service Use Only:

Program Code:

 Cross-Servicing Agency Profile

Program Information 

Program Name 

EIN

Debt Description 

Authorizing Statute 

Agency Location Code (ALC
Form Version 12/12/22 Revision 6 6

Program Detail Information 

Referred Principal TAS/BETC

Referred Interest TAS/BETC

Referred Penalty TAS/BETC

Referred Admin Cost TAS/BETC

IPAC Contact Information

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 7

Program Classification (select either Administrative Debts or Loans): 

Administrative Debts (select only one) Loans (select only one)

Business 

Education 

Housing 

Other (If selected, Desc. must be completed)

Desc.: 

Employee Advance 

Fee 

Fine 

Grant 

Miscellaneous (If selected, Desc. must be completed) 

Desc.: 

Overpayment

Penalty

State/Local Government

Yes No

.0%

Fiscal Service has FULL authority to compromise and/or collect debts in installments. 

If no, please answer the following:

Maximum Percent to be forgiven without obtaining CA concurrence: 

Minimum Monthly Payment Amount: 

Maximum Number of Months for Repayment: 

Waive interest during payment agreement: Yes No

Waive penalty during payment agreement: Yes No

If no, provide specific legal citation for why your agency cannot provide Fiscal Service with full compromise authority:

Cross-Servicing Agency Profile

Program Detail Information (Cont.) 
Form Version 12/12/22 Revision 6 8

Program Detail Information (Cont.) 

Agency is required to obtain Fiscal Service or DOJ approval for compromises, suspensions, or

terminations for debts with principal over $100,000.

Yes No

Note: Fiscal Service has delegated authority to compromise, suspend, or terminate debts with a principal balance up to $500,000. 

If no, specify dollar amount (or ‘unlimited’) up to which agency can compromise/terminate/suspend: 

If no, provide specific legal citation that authorizes your agency to compromise/terminate/suspend debts with principal balances 

>$500,000 without Fiscal Service or DOJ approval:

Batch File Processing: Yes No

Electronic File Contact Information

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 9

Program Collection Actions

Refer Debts to Private Collection Agency (PCA): Yes No

If no, confirm that agency uses independent PCA or provide specific legal citation for why PCA Referral is not required:

Perform Administrative Wage Garnishment (AWG): Yes No

If yes, provide citation of hearing procedure regulation that agency published:

If yes, AWG Authorization Date (mm/dd/yyyy): 

AWG Contact Information

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

If no, provide specific legal citation for why AWG not permitted:

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 10

Program Collection Actions (Cont.) 

Perform Credit Bureau Reporting: Yes No 

If yes, provide the “Original Creditor Name” that should be used for Credit Bureau Reporting (CBR):

If yes, begin reporting immediately or apply “Treasury Standard” Immediate Reporting Treasury Standard 

If no, confirm that agency is independently reporting or provide specific legal citation for why CBR is not required:

If no, confirm that agency is independently filing or provide specific legal citation for why 1099-C Filing is not required:

1099-C ContactInformation

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

File 1099-C for compromised and terminated debts: Yes No

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 11

Refer to Treasury Offset Program (TOP) Yes No 

If no, confirm that agency is independently referring or provide specific legal citation for why TOP Referral is not required. 

Use Cross-Servicing TOP Profile Yes No 

If no, indicate the payment types (Debt Match Bypass Indicators) against which debts should not be offset. 

SAL SSA Vendor RRB OPM NTV NSV NST

Provide specific legal citation and explanation for any bypass indicators selected:

When the debt has completed “active” collection activities via Cross-Servicing, it should remain “passive” at TOP. 

If yes, leave in TOP indefinitely? Yes No

If no, leave passive at TOP months if no offsets are taken.

Yes No 

 Cross-Servicing Agency Profile

Program Collection Actions (Cont.) 

Refer to Department of Justice (DOJ) for enforcement through litigation: Yes No 

If no, confirm that agency is independently referring or provide specific legal citation for why DOJ Referral is not required.
Form Version 12/12/22 Revision 6 12

Program Collection Actions (Cont.) 

Dispute ContactInformation

Primary Contact Information Alternate Contact Information

Name 

Address 

Address 

City 

State 

Zip 

Phone 

Fax 

Email 

Cross-Servicing Agency Profile
Form Version 12/12/22 Revision 6 13

Program Financial Information: Accruals Interest

Accrual Options: Choose only one:

Do not accrue interest. Provide legal citation:

Cross-Servicing will accrue interest 

Agency will provide adjustments for interest. Cross-Servicing will not accrue interest 

Penalty Accrual Options: Choose only one: 

Do not accrue penalty. Provide legal citation:

Cross-Servicing will accrue penalty.

Agency will provide adjustments for interest. Cross-Servicing will not accrue penalties. 

Program Financial Information: Bankruptcy

Debts in this program are dischargeable: Yes No

If no, provide specific legal citation for why debts are not dischargeable:

Cross-Servicing Agency Profile

Additional Fees and Accruals

Program Financial Information: Fees

Fees charged to the agency should be passed onto the debtor Yes No 

If no, provide specific legal citation for why fees are not allowed to be passed onto the debtor:
Form Version 12/12/22 Revision 6 14

Initial Profile: OR Updated Profile: 

Prepared by:

Telephone No.:

Date:

 Program Designation Code: / **/ / 

Approval to exempt the use of collection tools: 

PCA: Date: Approving Official:

Date: Approving Official:

Date: Approving Official:

Date: Approving Official:

Date: Approving Official:

Date: Approving Official:

Date: Approving Official:

AWG: 

CBR: 

1099-C: 

DOJ Referral: 

TOP Referral: 

Compromise authority: No 

Fiscal Service/DOJ 

approval:

Date: Approving Official:

Fiscal Service conducting hearings for: 

Salary: 

Hardship: 

AWG: 

Agency Liaison Notes:

For Fiscal Service Use Only:

Date Created:

Cross-Servicing Agency Profile