Information Disclosure Form

<% ' open connection %> <% on error resume next %> <% set dbconn = server.createobject("ADODB.Connection") %> <% dbconn.open "DSN=triggerit;UID=johnwhite;PWD=notthepassword;DATABASE=johnwhite" %> Information Disclosure Form <% securitypassfail = Request.querystring("security") If securitypassfail = "New" Then Response.Write("Thank You For Completing The Information Disclosure!") End If If securitypassfail = "Fail" Then Response.Write("Secuity code was blank or Incorrect. Your request was not processed. Please try again!") End If If securitypassfail = "Pass" Then Response.Write("Your request was processed Successfully.") End If %>

If you want us to provide information to a third party (i.e.: bank, lender, attorney, investor, etc) please complete this form.

Please complete all of the applicable information below:

	Form 1040 (specify years below)
	Corporate and/or partnership returns (specify years below)
	Audited financial statements
	Quickbooks backup file
	Payroll tax returns (specify years below)

Other documents (please list): <%=Request.QueryString("otherdocs")%>
Please indicate to whom the documents/information may be released. Please provide : Name, Address, Phone Number, Fax Number <%=Request.QueryString("releaseto")%>
Please indicate the authorization period dates (Dates to which this person may receive information): from: to:

Your information:

Name:
>

Company:
>

Address:

Home Phone:
>

Bus. Phone:
>

E-Mail:
>

Signed:
Date of Birth:	>
Dated:	>
<% securitypassfail = Request.querystring("security") If securitypassfail = "Fail" Then Response.Write("Secuity code was blank or Incorrect. Your request was not processed. Please try again!") End If If securitypassfail = "Pass" Then Response.Write("Your request was processed Successfully.") End If %>
Enter the code on the right:

I have read and understood the privacy statement.
I agree to waive any liability to Audit and Tax Solutions CPAs, Inc. regarding disclosure of confidential information as a result of using this form. I also understand that a reasonable fee may be charged for providing this information.

<% dbconn.close %>