ACCOUNTING - Business Consulting



10031 W. Roosevelt Rd., Ste 202
Westchester, IL 60154
(P) 872-888-7944
(F) 855-IVORY-IG


Consent to Disclosure of Tax Return Information

 _____ IVORY FINANCIAL SERVICES, INC. __________ (“we”, “us” and “our”)
                   Printed name of tax preparer

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 and, in certain limited circumstances, for purposes involving tax return preparation. 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 applying for a Refund Transfer (“RT”) product from Intuit Inc. (“Processor”) using banking services of Civista Bank (“Bank”). In order to have your refund processed by and through Processor, we must disclose all of your 2022 tax return information to Processor and Bank.

If you would like us to disclose your 2022 tax return information to Processor and Bank for this purpose, please sign and date your consent to the disclosure of your tax return information.

By signing below, you (including each of you if there is more than one taxpayer) authorize us to disclose to Processor and Bank all of your 2022 tax return information so that Processor can evaluate and process your application and Bank can provide banking services for the RT product. You understand that if you are not willing to authorize us to share your tax information with Processor and Bank, you will not be able to obtain an RT product from Processor, but you can still choose to pay us directly to have your tax return prepared and filed.

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

______________________________                 ________________________________
Taxpayer Signature:                                               Date:


Print Name