Authorization And Release Form - Bar Of The Supreme Court Of Pennsylvania Page 2
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2d.
I hereby request and authorize the Internal Revenue Service to release and
furnish to Disciplinary Counsel true and correct copies of my federal personal income
tax returns for the five tax years next preceding the date of the within authorization. I
also authorize and consent to the release by the Internal Revenue Service of any tax
return which I may have signed during said five years on behalf of a corporation,
partnership or other business association.
My social security number is
_________________.
e.
I hereby request and authorize any state or local taxing authorities (to
include income taxing authorities, personal property taxing authorities, wage taxing
authorities, school income taxing authorities and such other taxing bodies as may receive
returns from me) to furnish to Disciplinary Counsel any and all tax returns I have filed
during the five tax years next preceding the date of the within authorization. My social
security number is _________________.
I hereby release, discharge and exonerate Disciplinary Counsel and any person furnishing
information pursuant to the within authorization, from any and all liabilities of every nature and
kind arising out of the furnishing of or inspection of documents, records, and other information
released to or the investigation made by or on behalf of Disciplinary Counsel.
I certify that I have read the foregoing document and have answered all questions fully,
frankly and precisely. The answers are complete and are true to the best of my knowledge,
information and belief.
___________________
_______________________________
Date
Signature
Sworn to and subscribed
before me this ________
day of _______________, ______.
____________________________
Notary Public
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