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150 602 005 2013
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You must complete sections 1, 2, and 3 and check all boxes that apply.
Section 1
Information authorization: I allow my confidential OAA debt information to be disclosed to my designee.
Payment authorization: I authorize my designee to set up a payment plan, manage all payments and settlement offer(s), and resolve
issues with the settlement of my debt. I understand if payment obligations aren’t met, I will be subject to further collection activity.
Section 2
Note: From this date forward,...
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