Bank Disclosure Form

Consent for Disclosure of Information

Federal law requires this consent form be provided to you.  Unless authorized by law, we cannot disclose, without your consent, your tax return information to third parties for purposes other than the preparation and filing of your tax return.  If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution.

You are not required to complete this form.  If we obtain your signature on this form by conditioning our services on your consent, your consent will not be valid.  If you agree to the disclosure of your tax return information, your consent is valid for the amount of time that you specify.  If you do not specify the duration of your consent, your consent is valid for one year.

You have asked me to release your tax return information to a lender in order to expedite your loan process.  In order to do so, I need you to indicate your consent to disclose your tax return information by filling in the information below and signing where indicated.

Authorization

I/We, authorize your firm to release our tax returns, tax information and tax-related documents as detailed below to the following person and/or institution:

Duration of this consent for the information checked below (one year if blank):  ________

o   Any information which is requested

o   Only a copy of my tax return for the following year(s):  ____________

o   Only the following specific information:  ______________________

If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.