Consent To Release Tax Return Information
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1CONSENT TO RELEASE TAX RETURN INFORMATION
Federal law requires this consent form to 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.
*All parts of this form needs to be completely filled out.
*Each form can be used for only one entity.
*The duration of each consent form is only on an as needed basis.
*This form must be returned
1) Entity or person’s name and social security number or Federal Identification number
of tax returns being authorized:
Entity/Person’s name____________________________________________________
SSN/Federal ID# _______________________________________________________
2) Tax Form(s) and Tax Year(s) being authorized:
Tax Form(s) __________________________________________________________
Tax Year(s) ___________________________________________________________
3) Purpose for forwarding information:
Banking and/or Loan Requirements
Other (Please Specify)________________________________________________
__________________________________________________________________
4) Information is released to:
Name: ___________________________________________________________
Address: _________________________________________________________
City: __________________________ State: __________ Zip Code: __________
Phone Number: ____________________________________________________
E-mail Address:_________________________@____________________. ____
5) Method of delivery for tax information:
By E-mail
By Mail
Other ________________________________
6) Contact information if Sargent, Sargent, & Bryan, Inc. will need any further
information to complete the request to release your tax information:
Phone Number: ____________________________________________________
E-mail Address: ____________________________________________________
Other: ____________________________________________________________
I, ____________________________________, authorize Sargent, Sargent, & Bryan, Inc.
to disclose to the individual(s)/company listed above (‘4 Information is released to:’), my
tax return information for the person or entities listed above.
Signature ________________________________________ Date _____/_______/____
If you believe your tax return information has been disclosed or used improperly in a manner unauthorized
by the law without your permission you may contact the Treasury Inspector General for Tax
Administration (TIGTA) by telephone at 1-800-336-4484 or by e-mail at complaints@tigta.treas.gov.
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