Consent to Disclose Form

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose, without your consent, your tax return information to third parties for purposes rather than the preparation and filing of your tax return. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution.

You are not required to complete this form. Because our ability to disclose your tax return information to another institution affects the service that we provide to you, we may change the terms of service that we provide to you if you do not sign this form. If you agree to the disclosure of your tax return information, your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year.

You have indicated that you are interested in obtaining a bank account, refund settlement product, card service, and/or related banking services. These products are made available through arrangements that we have with financial with financial institutions and their partners. To apply for and obtain any of these products or services, we may forward your information to these companies and/or their affiliates.

If you sign this form and check the box below, you authorize us to disclose your (please indicate the tax year in the space provided above) tax return for the designated purposes.

I authorize Fresh Start to disclose my (please indicate the tax year in the space provided above) Tax Return and Information collected during the preparation of my taxes to ensure that any refund settlement products, and related banking services that I obtain or apply can be issued, processed, underwritten, and serviced. The foregoing activities and related services may be performed by one of the following companies and/or their affiliates.