Authorization to Disclose Financial Information

So that Tostevin Accountancy Corporation may protect your private financial information we need to document with whom our firm may discuss your financial matters and to whom our firm may provide various financial documents.  Please complete the following information, sign and return the form to us. 

We will not be able to provide any information or documents about your financial matters without the authorization in writing.  

When is it effective? This form will not be effective until Tostevin Accountancy Corporation has signed the form acknowledging receipt.  We will provide you with a copy of the signed and completed document. 

Cancellation of this Authorization. This form has a section at the end where you may cancel this document at anytime. The cancellation will not be effective until Tostevin Accountancy Corporation has signed the receipt acknowledging your cancellation request. 

Form Instructions:

Name - Enter the name of the individual, partnership, corporation or other entity that is making the authorization to Tostevin Accountancy Corporation.

Date - Normally today’s date but you may choose to provide authorization at some future date.

To Discuss the Following Matters - Enter the types of matters that you wish to authorize discussion about. For example, if you wish to authorize our firm to answer questions about your financial statements then enter here “Authorized to discuss any financial matters for the period of  (for example, the years of 2000 and 2001).”   Enter “N/A” in the box if not authorizing to discuss any financial matters.

To Provide the Following Documents - Enter the documents that you wish to authorize our firm to release. For example, if you wish to authorize release of a financial statement to a bank  “Authorized to provide a copy of the financial statements for the period of (for example, the years of 2000 and 2001).”  Enter “N/A”  in the box if not authorizing the release of any documents.

Name of Individual/Telephone Number/Fax Number/Address - Enter the name of the person we are authorized to either discuss or provide documents to about your financial matters. If we are to discuss or to provide information only to this certain individual at the company named below, then please place a checkmark in the box.  No entry in the box means that we may discuss or provide documents to any employee of the company named below.  Enter telephone, fax, and address of the person/company.

Name of Company – Enter the name of the company with whom the individual named above is with. 

Signature/Date - Sign and date authorizing the release of the information and/or documents. If the client is an entity other than an individual, then the individual by their signature acknowledges that they are authorized by the entity to authorize the release of such information and/or documents.

Receipt Signature/Date - Signature and date when we acknowledge receipt of authorization.

Cancellation Signature/Date - If you wish to cancel this authorization please sign and enter a date it is effective as of what date.

Receipt of Cancellation Signature/Date - Only a partner (no employees) of Tostevin Accountancy Corporation may acknowledge receipt of a cancellation of an authorization.  Date entered is the effective date of the cancellation.