Appendix W3. Paycheck Plus IRS Consent to Use Form

OMB Control No. 0970-0413

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Appendix W3

MDRC IRS CONSENT TO USE FORM

Consent to Use Taxpayer Information Collected During All Years of the Paycheck Plus Study

United Way has been chosen to take part in the Paycheck Plus Study, an expansion demonstration of income tax credit. MDRC, a not-for-profit research company is working with United Way to conduct the Paycheck Plus study. A survey firm will also help MDRC gather information for the study.

Thank you for expressing your interest in taking part in the Paycheck Plus Study. By signing this form you will be giving your consent to MDRC to use information from your tax return and other information collected at United Way during 2016, 2017, 2018, and 2019.

INFORMATION:

Full Name and Date of Birth	Sources of Income	Earnings from W2 forms
Social Security Number	Taxes and Credits	Business Income
Contact information	Adjusted Gross Income	Business Net Profit/Income
Filing status and Refund Amounts	Number of Dependents	Date of filing

USE: To help MDRC

1. Facilitate payment of your earning bonus, if you are selected into the Paycheck Plus group.

2. Help a survey firm possibly contact you at a later date and invite you to answer additional survey questions.

3. Conduct research on the effects of the Paycheck Plus study.

CONSENT GRANTED: I/we the taxpayer(s), have read the above information and hereby CONSENT to MDRC's use information from my/our tax return for the purposes stated above. Duration of Consent: 5 years.

Taxpayer signature: ____________________________ Date: _____________________

Print name: __________________________________

Spouse’s signature: ___________________________ Date: _____________________

Print name: __________________________________

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

You are not required to complete this form. If we obtain your signature on this form by conditioning our services on your consent, your consent will not be valid. 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.

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 [email protected].