CONSENT TO DISCLOSURE OF TAX INFORMATION

I authorize the Internal Revenue Service to disclose any of my returns and return information, as those are defined in section 6103 (b) of the Internal Revenue Code, for the tax year(s) listed below to U.S. Representative Marion Berry or members of his staff.

I also authorize the Internal Revenue Service to disclose this information to any person to the extent that the Internal Revenue Service seems necessary to clarify any matter pertaining to this information that is published, discussed, or otherwise disseminated in the public record.

I am aware that, without this authorization, my returns and return information are confidential and are protected by law under the Internal Revenue Code.

Taxpayer's Name:

Please Print

Identifying Number:

Address:

City: State Zip

Phone:

Tax Year(s)Waived: through inclusive. 

Taxpayers's Signature:____________________________________________

Date:__________________________________________________

Note:  Treasury Regulations require that the Internal Revenue Service must receive your consent within 60 days following the date on which you sign and date this consent form