Client Information:
Your Name:
As of this date -- mm/dd/yy, the firm, employees and agents of Tostevin Accountancy Corporation are authorized to discuss the following matters and/or provide the following documents:
To whom the firm, employees of Tostevin Accountancy Corporation are authorized to discuss the above matters and to whom we may provide the above documents:
Please provide the following contact information:
Discuss/provide information only to this person at the named company.
Name Street Address Address (cont.) City State/Province Zip/Postal Code Country Work Phone FAX
Company Name
By your signature below you are authorizing Tostevin Accountancy Corporation to make the disclosures listed above and to release the documents listed above. This authorization does not require Tostevin Accountancy Corporation to make such disclosure or to release such documents. Tostevin Accountancy Corporation has the right to not make such disclosure or not to release such documents if any fees are due to us or if you have not made arrangements for payment of any fees for the disclosure of such information or release of such documents. Work may be stopped at any time because fees are due Tostevin Accountancy Corportion and not paid. You acknowledge that Tostevin Accountancy Corporation will not be liable for not disclosing such information or releasing such documents. Tostevin Accountancy Corporation will not be liable for any actual disclosure of information or any actual release of documents under this authorization.
Please provide your signature:
Date of signature:
-- mm/dd/yy
For Tostevin office use only:
Signature of partner or employee acknowledging receipt of authorization:
Date of signature acknowledging receipt of authorization:
I wish to cancel the above authorization for Tostevin Accountancy Corporation to discuss any matter listed above and to provide any documents listed above. This cancellation of the authorization is not effective until acknowledged by a partner of Tostevin Accountancy Corporation. Tostevin Accountancy Corporation is not liable for any disclosure of information or any release of documents prior to acceptance of the cancellation by us.
Date cancellation effective :
(Click here for instructions)