Consent To Use Personal Tax Return Information (Page 2 of 2) in pdf

Consent To Disclose Personal Tax Return Information

Federal Disclosure:

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. The duration specified below can

be changed if desired. If you do not specify the duration of your consent, your consent is valid for one year.

Defined Terms:

"Tax Preparer*":

Prep-R-Us, 225 Chastain Meadows Ct NW, Kennesaw, GA 30144

"Taxpayer #1":

"Taxpayer #2":

"Taxpayer": Refers to both Taxpayer #1 and Taxpayer #2

"Personal Information": Taxpayer's 2011 tax return and all information contained therein

"PIN": Personal identification number

"Disclosure":

"Purpose":

CONSENT GRANTED

I/we, the Taxpayer, have read the above information. By typing in my/our taxpayer PIN(s), I/we hereby

consent to the Disclosure for the Purpose stated above.

Taxpayer #1 PIN:

PIN Entered Date:

Taxpayer #2 PIN:

PIN Entered Date:

Duration of Consent: 3 years

LIMITATION ON DISCLOSURE

I/we do not wish to limit the scope of the Disclosure of the Personal Information unless I/we mark the

box and list the limitations below.

Tax Return Disclosure Limitation:

CONSENT DENIED

I/we, the Taxpayer, have read the above information, and by typing in my/our taxpayer PIN(s) hereby

DENY consent to the Disclosure of the Personal Information for the Purpose stated above.

Taxpayer #1 PIN:

PIN Entered Date:

Taxpayer #2 PIN:

PIN Entered Date:

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.

* In accordance with Federal Law and Internal Revenue Code Section 7216, the term 'Tax Preparer' shall mean the

ERO of this electronically filed return even though it may have been prepared by someone other than the ERO.

Consent To Use Personal Tax Return Information Page 2