7216 Individual

At Herbein + Company, Inc., we place a high value on your privacy and the security of your personal information. We have always had policies in place to safeguard the paper and electronic information you provide to us.

There are recent federal regulations in place to help to ensure that all tax preparers handle clients’ information with care, in addition to those safeguards we previously employed. The regulations require that we obtain your written consent before we use or disclose your information for any purpose other than preparing your tax return, such as recommending services or sending you our firm newsletter or collaborating with non-US based colleagues. Please consider the enclosed forms carefully.

Please note that you are not required to sign and return these forms in order to keep doing business with Herbein + Company, Inc. You may give your consent for all, some, or none of the situations. However, without your signed consent, we cannot contact you regarding matters that do not relate directly to your tax return and you might not receive our newsletters, eNewsletters, event invitations, or other Herbein + Company, Inc. news.

To give us your consent, please complete the survey below prior to the completion of your tax return.

For questions or additional information, contact your Herbein advisor directly or via 1.855.HC.TODAY.

Consent to Disclosure of Tax Return Information

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent. 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 to engage our tax return preparation services. If we obtain your signature on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. 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 from the date of signature.

Name of financial advisor/name of bank:*

This consent authorizes the disclosure of a copy of your entire tax return and all information contained within your tax return

Purpose for disclosing information (Check one or both):*

Providing a copy of your entire tax return to your financial advisor to assist in advising you on retirement plans such as an IRA, SEP, or Roth IRA, purchase or sale of investments, managed funds accounts, and otherwise advise you on your financial investments.Providing a copy of your entire tax return to your bank, mortgage company, or other third party to satisfy loan covenants or to apply for new or additional credit.None of the above

Name of recipient:*

First NameLast Name

The duration of this consent will continue as indicated below, unless Herbein & Company, Inc. is notified in writing to no longer disclose your tax return information to this recipient:*

Remain effective to the extent Herbein & Company, Inc. is engaged.Other

If you approve the disclosure of your tax return information to the recipient named above and for the duration indicated, please sign below. (If married, both spouses must sign the consent)

Your Name*

First NameLast Name

Signature: Typing a name here represents a signature*

Form Completed*

Date

Spouse's Name

First NameLast Name

Spouse's Signature: Typing a name here represents a signature

Form Completed

Date

Consent to Foreign Disclosure of Tax Return Information

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your tax return information to third parties for purposes other than the preparation and filing of your tax return without your consent. 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 tax return preparer affects the tax return preparation service(s) that we provide to you and its (their) cost, we may decline to provide you with tax return preparation services or change the terms (including the cost) of the tax return preparation services 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 from the date of signature.

This consent to disclose may result in your tax return information being disclosed to a tax return preparer located outside the United States, including your personally identifiable information such as your Social Security number (SSN). Both the tax return preparer in the United States that will disclose your SSN and the tax return preparer located outside the United States that will receive your SSN maintain an adequate data protection safeguard (as required by the regulations under 26 U.S.C. section 7216) to protect privacy and prevent unauthorized access of tax return information. If you consent to the disclosure of your tax return information, federal agencies may not be able to enforce United States laws that protect the privacy of your tax return information against a tax return preparer located outside of the United States to whom the information is disclosed.

The duration of this consent will continue as indicated below, unless Herbein & Company, Inc. is notified in writing to no longer disclose your tax return information to this recipient:*

Remain effective to the extent Herbein & Company, Inc. is engagedOther

If you approve the disclosure of your tax return information, including your SSN(s), to Herbein & Company, Inc. employees located in the Philippines for purposes of assisting in providing tax return preparation services for the duration indicated above, please sign below. (If married, both spouses must sign the consent)

Your Name*

First NameLast Name

Signature: Typing a name here represents a signature*

Form Completed*

Date

Spouse's Name

First NameLast Name

Spouse's Signature: Typing a name here represents a signature

Form Completed

Date

Consent to use of Tax Return Information

Federal law requires this consent form be provided to you. Unless authorized by law, we cannot use your tax return information for purposes other than the preparation and filing of your tax return without your consent.

You are not required to complete this form to engage our tax return preparation services. If we obtain your signature on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. Your consent is valid for the time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from the date of signature.

You hereby consent to the use by Herbein & Company, Inc. of all tax return information contained in your federal income tax returns (Forms 1040, 1040NR, etc., and supporting schedules) for the purpose of mailing, including electronic transmission, of information pertaining to

Please check all boxes for which the consent applies:*

Newsletters, eNewsletters, event invitations, firm news and other information of Herbein & Company, Inc.Providing information to you regarding additional services that might be appropriate, including tax planning, estate planning, accounting or other personal or business consulting, from one of our affiliated companies.None of the above

The tax information may not be disclosed or used by Herbein & Company, Inc. for any purpose other than that permitted by this consent document.

The duration of this consent will continue as indicated below, unless Herbein & Company, Inc. is notified in writing to no longer disclose your tax return information to this recipient:*

Remain effective to the extent Herbein & Company, Inc. is engagedOther

If you approve the use of your tax return information by Herbein & Company, Inc. for the duration indicated above, please sign below. (If married, both spouses must sign the consent)

Your Name*

First NameLast Name

Signature: Typing a name here represents a signature*

Form Completed*

Date

Spouse's Name

First NameLast Name

Spouse's Signature: Typing a name here represents a signature

Form Completed

Date

If you believe your tax return information has been disclosed or used improperly in a manner unauthorized by law or without your permission, you may contact the Treasury Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484 or by email at complaints@tigta.treas.gov.

For Individual Taxpayers