Authorization Of Services And Disclosures Page 2

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Form E
Below are pre-qualifiers for a RAL Check. If any pertain to me/us, I/we understand that the
bank will automatically issue an Electronic Refund Check (ERC).
These are federal
guidelines that must be followed. *Please initial beside each statement. (Let your preparer
know if questions may pertain to you or your spouse.)
Taxpayer
Spouse
1. ________
________ I (We ) do not owe any tax due and/or are not subject to any tax lien from prior
tax years.
2. ________
________ I (We) have not previously filed a Federal/State Income tax return for this tax
year.
3. ________
________ I (We) do not owe any delinquent child support and/or alimony payments, student
loans, V.A. Loans or other Federally sponsored loans.
4. ________
________ I (We) do not have a petition (voluntary or involuntary) presently filed under any
State or Federal bankruptcy or insolvency laws.
5. ________
________ I (We) have not paid any estimated tax and/or did not have any amount of our
last year’s refund applied to our tax return for this year.
6. ________
________ I (We) have not had a RAL with any RAL lender which has been discharged
in bankruptcy.
7. ________
________ I (we) are not active military personnel nor are we the dependant of an active
member of the Military.
I/We, hereby declare all the statements and information I’ve/we’ve given to the tax preparer and employees
are true and correct. I/We understand that I/we am/are applying for a Refund Anticipation Loan (RAL)
based upon the refund amount. This is a loan between me/us (the taxpayer/spouse) and the bank. I/We
further understand that all unpaid fees or charges owed to the tax preparer will be deducted from my/our
loan check. I/We hereby authorize and request that the tax preparer submits all tax return information to
the bank for evaluation of a Refund Anticipation Loan (RAL).
_________________________________________
______________________________________
Signature -
Taxpayer
Date
Signature -
Spouse
Date
I/we have been provided with clear explanations of the various ways of filing returns and the
additional costs associated with each as well as a complete list of all fees associated with
my Refund Anticipation Loan (RAL).
__________________________________________ _________________
Taxpayer
Date
__________________________________________ _________________
Spouse (if applicable)
Date
Page 2
Authorization of Services & Disclosures

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