EFTA01220947.pdf

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION ("we," "us" and "our") Printed name of tax preparer 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 your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent. 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 to engage our tax return preparation services. If we obtain your signature on this form by conditioning our tax return preparation 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 from the date of signature. You have indicated that you are interested in obtaining an Electronic Refund Product from Fort Knox Financial Services Corporation, d/b/a Refund Advantage (the "Service Provider"). To provide you with the opportunity to apply for and/or receive an Electronic Refund Product, we must disclose all of your 2014 tax return information to the Service Provider. You may request a more limited disclosure of tax return information, but you will not be eligible to submit an application for an Electronic Refund Product to the Service Provider. If you would like us to disclose your 2014 tax return information to the Service Provider for this purpose, please sign and date your consent to the disclosure of your tax return information. By signing below, you authorize us to disclose to the Service Provider all of your 2014 tax return information so that the Service Provider can evaluate and process your application for an Electronic Refund Product. You understand that if you are not willing to authorize us to share your tax information with the Service Provider, you will not be able to obtain an Electronic Refund Product from the Service Provider, but you can still choose to have your tax return prepared and filed by us for a fee. Printed Name of Taxpayer: Taxpayer Signature: Date: Printed Name of Joint Taxpayer: Joint Taxpayer 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. Refund Advantage Integration Specifications —20I4/I5 Page 49 EFTA01220947