Consent_for_Credit_Report.docx

CONSENT FOR RELEASE OF CONSUMER CREDIT REPORT TO THE UNITED STATES SECURITIES AND EXCHANGE COMMISSION

This voluntary consent authorizes the United States Securities and Exchange Commission (“SEC”) to obtain copies of my consumer credit report for use by the SEC staff in reviewing the proposal submitted by _________________________________________[insert name of entity] to provide tax compliance and administration services during the calendar years ending December 2016, 2017 and 2018. I acknowledge that no promises or representations have been made by the SEC staff or any member, officer, employee, agent or representative of the SEC as consideration for this consent.

Accordingly, I, (Name), (SSN/EIN), (Address), hereby authorize any and all consumer credit reporting service companies to release all information concerning my credit history to the SEC staff or any member, officer, employee, agent or representative of the SEC. I understand that this authorization may be revoked by me in writing at any time before my consumer credit report is released to the SEC, and that this authorization is valid for no more than three months from the date of my signature.

Signature of Consentor Date

STATE OF )

) ss.

COUNTY OF )

On this day of , , , being known to me to be the person who executed the foregoing CONSENT FOR RELEASE OF CREDIT REPORT TO THE UNITED STATES SECURITIES AND EXCHANGE COMMISSION, personally appeared before me and did duly acknowledge to me that he executed the same.

NOTARY PUBLIC

image1.png