Consent To Disclosure Of Tax Return Information (Form 1040 - Individual)

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FORM 1040 -- INDIVIDUAL
CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION
Federal law requires this consent form be provided to you. Unless authorized by law, we cannot
disclose your tax return information to third parties for purposes other than the preparation and
filing of your tax return without your consent. 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 to engage our tax return preparation services. If we
obtain your signature on this form by conditioning our tax return preparation 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 from the date of signature.
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.
Please complete:
Purpose for forwarding information:__________________________________________
______________________________________________________________________
______________________________________________________________________
Name and address to whom information is being disclosed to:_____________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Duration of Consent:______________________________________________________
I/we, ____________________________________________, authorize Greenberg, Rosenblatt,
Kull & Bitsoli, P.C. to disclose to the above name my/our tax return information for 20_______.
The tax return information may not be disclosed or used by Greenberg, Rosenblatt, Kull &
Bitsoli, P.C. for any purpose (not otherwise permitted without formal consent) other than that
permitted by this consent document.
Signed this __________ day of ______________________, 20_______.
_______________________________
__________________________________
Taxpayer
Spouse (if applicable)
(REV 3-13)

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