Tax Service Acknowledgement and Consent
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Tax Service Acknowledgement and Consent
Acknowledgement that Services Provided by Health and Economic Opportunity Program Are Not Legal Services at Pisgah Legal Services
Through its Health and Economic Opportunity Program (“HEOP”), Pisgah Legal Services (“
PLS
”)
provides enrollment assistance
in the
AC
A
health insurance
m
arketplace
,
prepares
income tax returns for qualified taxpayers
, and assists with limited tax-related issues
. These services are provided by non-attorney staff and are operated separately and distinctly from any legal services at PLS
.
I understand that HEOP services at PLS are not legal services and do not provide the protections of an attorney-client relationship. The provision of HEOP services at PLS does not
create an attorney-client relationship, does not give rise to attorney-client privilege, and does not constitute legal representation or legal services whatsoever.
Check box to give consent.
Consent to Disclosure of Tax Return Information
Unless authorized by law,
tax preparers (including support staff)
are prohibited from disclosing your tax information to any third party without your express consent.
This means
no
HEOP staff
member
can share your tax return information with a
PLS
attorney unless you
give HEOP staff permission to do so. Similarly, no PLS attorney can share your tax return information with HEOP staff unless you give your attorney permission to do so. You are not required to grant permission to share this information, and legal representation is not conditioned upon your grant of authority. If you agree to permit the HEOP staff and PLS attorney to share information, your consent is valid only
for reasonable and appropriate purposes related to assistance in your tax matters, and it extends
for
one year from the date of signature.
I request and authorize HEOP
to disclose information obtaine
d while assisting me with my legal, health insurance, or tax matters to PLS legal services staff, as
deem
ed
appropriate and reasonably necessary
. This includes, but is not limited to, the exchange of my tax documents and information between HEOP and PLS legal services staff
.
Check box to give consent.
I request and authorize HEOP to disclose information obtained while assisting me with my legal, health insurance, or tax matters to the Internal Revenue Service via form, letter, telephone and/or online portal, as deemed appropriate and reasonably necessary to assist with information gathering for tax preparation-related purposes.
Check box to give consent.
I understand
that the duration of this consent is one year from the date of my signature below.
Check box to give consent.
I have read and understand this Acknowledgement and Consent and agree to the terms herein, as
evidenced
by my signature.
Type out your full name for your signature.
Date of Consent
Contact Information