Online Forms

Form 1: To release information to bankers, mortgage companies

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION

 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.

Please complete:  [To be completed by the taxpayer.]

  • Purpose for forwarding information: _____________________________________

___________________________________________________________________

___________________________________________________________________

  • Name and address to whom the information is being disclosed to:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

  • Duration of Consent: ___________________________________

I,  ____________________________________________________,

authorize Fillo Financial LLC, One Hollis Street, Suite 301, Wellesley, MA 02482 to disclose to _____________________________________________________________________________

my tax return information for tax year 20___.

Signature: ______________________________________________ Date: _______________

Printed Name: ___________________________________________

If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email to: complaints@tigta.treas.gov

 

 

 

Consent 2: To release information to financial services adviser/firm

 

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose, without your consent, your tax return information for purposes other than the preparation and filing of your tax return.

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. 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.

The purpose of this consent is to allow us to disclose your tax return information to

_________________________________________________________
(name of financial services firm) to assist in advising you on retirement plans such as an IRA, SEP, or Roth IRA, purchase or sale of investments, managed funds accounts, and otherwise advise you on your financial investments.

_______________________________ is a Registered Investment Advisor Agent and his license is held at

______________________________________________________________________
(name of financial services firm).  By signing this consent you also acknowledge that if you make an investment

with ______________________________________________________________________
(name of financial services firm) that ___________________________(name of Registered Investment Advisor) will receive a part of any management fees or commissions paid on investments you make as a result.

We are not allowed by Federal law to use your tax information for any purpose other than to prepare your tax return unless you permit us by signing this statement.

If you approve this disclosure of your tax return information by Fillo Financial LLC, One Hollis Street, Suite 301, Wellesley, MA 02482 for a term of one year, please sign below.

Signature: __________________________________________Date: ________________________

Print Name: ___________________________

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.