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Disclosure Form

CONSENT FOR DISCLOSURE OF TAX INFORMATION

 

 

Client(s):

(Name)

(Address)

(City, State, Zip)

Date

 

I/We, _____________________________, hereby request and authorize Helen P O’Planick, EA of The Offices of Helen P. O’Planick EA and HELJAN Associates, LLC to release our tax returns, tax information and tax-related documents as detailed below to the following person and/or institution:

 

NAME:  ____________________________  ORGANIZATION:  ________________________________

ADDRESS:  _____________________________________________________________________________

CITY  ___________________________________  STATE ________  ZIP _________________________

TELEPHONE  _________________________  FAX  ____________________________

E-MAIL __________________________________________________________________

 

Purpose of This Disclosure  ________________________________________________________________________________

________________________________________________________________________________

 

Specific tax information and documents to be released:

________________________________________________________________________________

________________________________________________________________________________

 

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.

 

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.

 

This consent will expire thirty (30) days from the date of the client signatures below.

 

______________________________________________________          ______________

          Taxpayer Signature                                                          Date

 

______________________________________________________          ______________

          Spouse Signature (if joint return)                                       Date