2019 Return
2019 Return
Card
We're going to disclose the tax information described from your 2019 tax return to First Century Bank (the
lender), BorrowWorks (the lender service provider) and Green Dot Bank (the issuer of the card) to
process your Refund Advance loan, administer and communicate with you regarding the loan program,
and to issue and manage a Turbo® Visa® Debit Card account for you.
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
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.
Do you agree to let TurboTax share your tax information with First Century Bank, Green Dot Bank
and BorrowWorks?
Today’s Date
Personal and contact information for primary filer and, if applicable, spouse: first and last name;
Social Security number; date of birth; address (street, city, state, zip, country); email address; phone
number; number of dependents; EFIN; military paygrade; driver’s license or state ID number.
Filing and preparation information: federal and state tax return type; tax year; filing status and history;
whether you are filing IRS Forms 4136, 1310 or 8888; when you agree to this disclosure consent; when
the IRS and state accepted the return; the IRS and state acknowledgement code for the return
Income and gain from any source (such as wages, tips, pensions, rental income, and capital
gains), and related forms (such as Forms W2 and 1099); adjusted gross income; taxable income
All deductions, credits and benefits (such as standard deduction, itemized deductions like
charitable contributions, education credits, earned income tax credit, and dependent care
benefits), and related federal and state forms (such as Schedules A and C, and Form 8862)
All losses and expenses (such as capital losses, theft losses, and business expenses) and
related federal and state forms (such as Schedule E and Form 4684)
Refund and tax liability information: current and prior tax year refund, if any, and how you
received or are receiving your refund; amount and type of all taxes paid or withheld for the current
and prior year, and related federal and state forms (such as Forms 4868 and 1099R)
Information regarding use of TurboTax, including methods and devices used to provide information to
TurboTax and TurboTax use history:
• Indicators on how you provided information to TurboTax
• Indicators regarding the device used to provide information to TurboTax
• Information about your TurboTax use, the amount paid for such product and your filing history and
status
We’re going to review your tax info to see if you’re eligible for a Refund Advance loan on a Turbo®
Visa® Debit Card.
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 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.
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.
Do you agree to let TurboTax review your tax information to see if you're eligible for Refund Advance?
Today’s Date
Filing Status Single Married filing jointly Married filing separately (MFS) Head of household (HOH) Qualifying widow(er) (QW)
Check only If you checked the MFS box, enter the name of spouse. If you checked the HOH or QW box, enter the child’s name if the qualifying person is
one box.
a child but not your dependent. a
Your first name and middle initial Last name Your social security number
Andrew W Lindsey 231-77-6919
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
Check here if you, or your spouse if filing
1534 N 18th St 2R
jointly, want $3 to go to this fund.
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions). Checking a box below will not change your
Philadelphia PA 19121-4253 tax or refund. You Spouse
Foreign country name Foreign province/state/county Foreign postal code If more than four dependents,
see instructions and here a
Age/Blindness You: Were born before January 2, 1955 Are blind Spouse: Was born before January 2, 1955 Is blind
Dependents (see instructions): (2) Social security number (3) Relationship to you (4) if qualifies for (see instructions):
(1) First name Last name Child tax credit Credit for other dependents
Sign Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true,
correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
F
Go to www.irs.gov/Form1040 for instructions and the latest information. BAA REV 01/02/20 Intuit.cg.cfp.sp Form 1040 (2019)
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
2019
(Form 1040 or 1040-SR)
a Attach to Form 1040 or 1040-SR.
Department of the Treasury Attachment
Internal Revenue Service a Go to www.irs.gov/Form1040 for instructions and the latest information. Sequence No. 01
Name(s) shown on Form 1040 or 1040-SR Your social security number
Andrew W Lindsey 231-77-6919
At any time during 2019, did you receive, sell, send, exchange, or otherwise acquire any financial interest in any
virtual currency? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . . . . 1 0.
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions) a
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . . . 3
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . . . . . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . . 7
8 Other income. List type and amount a
8
9 Combine lines 1 through 8. Enter here and on Form 1040 or 1040-SR, line 7a . . . . . . . . 9 0.
Part II Adjustments to Income
10 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
11 Certain business expenses of reservists, performing artists, and fee-basis government officials. Attach
Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . . . 12
13 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . . . . 13
14 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . 14
15 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . . . 15
16 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . . . 16
17 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . . 17
18a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . a
c Date of original divorce or separation agreement (see instructions) a
19 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . . 20 131.
21 Tuition and fees. Attach Form 8917 . . . . . . . . . . . . . . . . . . . . . . 21
22 Add lines 10 through 21. These are your adjustments to income. Enter here and on Form 1040 or
1040-SR, line 8a . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 131.
For Paperwork Reduction Act Notice, see your tax return instructions. REV 01/02/20 Intuit.cg.cfp.sp Schedule 1 (Form 1040 or 1040-SR) 2019
1900116342
PA-40 - 2019
Pennsylvania Income Tax Return
ENTER ONE LETTER OR NUMBER IN EACH BOX (07-19)
850-889-5324 51500
1a Gross Compensation. Do not include exempt income, such as combat zone pay and 1a 25661
qualifying retirement benefits. See the instructions.
10 Other Deductions. Enter the appropriate code for the type of deduction. N 10 0
See the instructions for additional information.
11 Adjusted PA Taxable Income. Subtract Line 10 from Line 9. 11 25661
Page 1 of 2
EC OFFICIAL USE ONLY FC
1900116342
1900116357
PA-40 - 2019
Social Security Number
32 Refund donation line. Enter the organization code and donation amount. See instructions. 32
33 Refund donation line. Enter the organization code and donation amount. See instructions. 33
34 Refund donation line. Enter the organization code and donation amount. See instructions. 34
35 Refund donation line. Enter the organization code and donation amount. See instructions. 35
36 Refund donation line. Enter the organization code and donation amount. See instructions. 36
Signature(s). Under penalties of perjury, I (we) declare that I (we) have examined this return, including all
accompanying schedules and statements, and to the best of my (our) belief, they are true, correct, and complete.
Your Signature Spouse’s Signature, if filing jointly
1900116357 1900116357
PA SCHEDULE W-2S 1901910024
Wage Statement Summary
Payment type: A. Executor fee B. Jury duty pay C. Director’s fee D. Expert witness fee
E. Honorarium F. Covenant not to compete G. Damages or settlement for lost wages, other than personal injury
H. Other nonemployee compensation. Describe:
I. Distribution from employer sponsored retirement, pension or qualified deferred compensation plan
J. Distribution from IRA (Traditional or Roth) K. Distribution from Life Insurance, Annuity or Endowment Contracts
L. Distribution from Charitable Gift Annuities M. Distribution from Employee Stock Ownership Plan
Describe:
1555
REV 12/13/19 INTUIT.CG.CFP.SP
1901910024 1901910024