Disclosure Authorization

Federal law requires this consent form be provided to you (“you” refers to each taxpayer, if more than one). 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.

Duration of consent (optional): ______________________

I (We), ___________________________________________, authorize Theresa Durkin, EA and Durkin Associates to disclose the following tax return and accompanying supplementary information:

__________________________________________________________________________

for the following year(s) _______________ to the following person or firm:

Name: _____________________________   Firm: ____________________________

Address: ______________________________________________________________

Phone: ______________________________ Fax: _____________________________

Email address: _________________________________________________________

Purpose: _______________________________________________________________

 

________________________            _____________________      _______________

Taxpayer’s Name                                Taxpayer’s Signature              Date

 

________________________            _____________________      _______________

Spouse’s Name                                   Spouse’s Signature                 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 .