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Form 8879
(Rev. January 2021)
IRS e-file Signature Authorization
OMB No. 1545-0074
u ERO must obtain and retain completed Form 8879.
Department of the Treasury
Internal Revenue Service u Go to www.irs.gov/Form8879 for the latest information.

Submission Identification Number (SID)

Social security number
Taxpayer's name
CORY W GRIESEMER 324-52-3449
Spouse's social security number
Spouse's name
ASHLEY R GRIESEMER 436-33-1242
Part I Tax Return Information — Tax Year Ending December 31, 2021 (Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 129,584
2 Total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 20,492
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 10,602
4 Amount you want refunded to you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
5 Amount you owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 8,586
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537 . Payment cancellation requests must be received no later than 2
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my
Electronic Funds Withdrawal Consent.
Taxpayer’s PIN: check one box only
X I authorize KINDY & ELLIOTT to enter or generate my PIN 21390 as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.

Your signature u Date u 10-17-22

Spouse’s PIN: check one box only
X I authorize KINDY & ELLIOTT to enter or generate my PIN 22740 as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros

I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.

Spouse’s signature u Date u 10-17-22

Practitioner PIN Method Returns Only—continue below
Part III Certification and Authentication — Practitioner PIN Method Only
ERO's EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 71180105294
Don’t enter all zeros

I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
requirements of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.

ERO’s signature u Date u

ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. Form 8879 (Rev. 01-2021)
DAA
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ULTRATAX
2021
AR8453
ARKANSAS INDIVIDUAL INCOME TAX
DECLARATION FOR ELECTRONIC FILING
Primary's Legal First Name and Middle Initial Last Name Primary's Social Security Number

• CORY W • GRIESEMER • 324-52-3449

Spouse's Legal First Name and Middle Initial Last Name Spouse's Social Security Number

ASHLEY R
Mailing Address (Number and Street, P.O. Box or Rural Route)
GRIESEMER • 436-33-1242
Telephone
581 CRESTRIDGE DRIVE
City State or Province ZIP
• 501-952-8628
Check if address is outside U.S.
MALVERN AR 72104 Foreign Country
PART I - TAX RETURN INFORMATION (Whole Dollars Only)
1. Total Income (Form AR1000F or AR1000NR, Line 23) ............................................................... 1 128,257 00
2. Net Tax (Form AR1000F or AR1000NR, Line 38) .................................................................... 2 4,160 00
3. State Income Tax Withheld (Form AR1000F or AR1000NR, Line 39) ................................................ 3 • 4,194 00
4. Refund (Form AR1000F or AR1000NR, Line 47) ..................................................................... 4 34 00
5. Tax Due (Form AR1000F or AR1000NR, Line 51) .................................................................... 5 00
PART II - DECLARATION OF TAXPAYER

6a. X I consent that my refund be direct deposited as designated in the electronic portion of my 2021 Arkansas income tax return. If I have filed
a joint return, this is an irrevocable appointment of the other spouse as an agent to receive the refund. The refund will be direct deposited to
the bank account(s) shown on page 1 the Form AR1000F/AR1000NR.

6b. I do not want direct deposit of my refund or I am not receiving a refund.

6c. I authorize the State of Arkansas Income Tax Section to initiate debit entries to my account as indicated on the Arkansas Income Tax Payment
form (AR TAX PMT).

6d. I authorize the State of Arkansas Income Tax Section to initiate debit entries to my account as indicated on the Arkansas Estimated Tax
Payment form (AR EST PMT) or Arkansas Extension Payment form (AR EXT PMT).

If I have filed a balance due return, I understand that if the State of Arkansas does not receive full and timely payment of my tax liability, I will remain liable
for the tax liability and all applicable interest and penalties. If I have filed a joint federal and state return and my federal return is rejected, I understand my
state return will be rejected also.
Under penalties of perjury, I declare that the information I have given my ERO and the amounts in Part I above agree with the amounts on the corresponding
lines of the electronic portion of my 2021 Arkansas income tax return. To the best of my knowledge and belief, my return is true, correct, and complete. I
consent to my ERO sending my return, this declaration, and accompanying schedules and statements to the State of Arkansas. I also consent to the State
of Arkansas sending my ERO and/or transmitter an acknowledgement of receipt of transmission and an indication of whether or not my return is accepted,
and if rejected, the reason(s) for the rejection. If the processing of my return or refund is delayed, I authorize the State of Arkansas to disclose to my ERO
and/or transmitter the reason(s) for the delay, or when the refund was sent. In addition, by using a computer system and software to prepare and transmit my
return electronically, I consent to the disclosure to the State of Arkansas of all information pertaining to my use of the system and software and to the
transmission of my tax return electronically.

Sign 10-17-22 10-17-22

Here Primary's Signature Date Spouse's Signature Date
PART III - DECLARATION OF ELECTRONIC RETURN ORIGINATOR (ERO) AND PAID PREPARER
I declare that I have reviewed the above taxpayer's return and that the entries on Form AR8453 are complete and correct to the best of my knowledge. If I
am only a collector, I understand that I am not responsible for reviewing the taxpayer's return; I declare that Form AR8453 accurately reflects the data on
the return. I have obtained the taxpayer's signature on Form AR8453 before submitting this return to the State of Arkansas, and have provided the taxpayer
with a copy of all forms and information to be filed with the State of Arkansas. If I am also the Paid Preparer, under penalties of perjury I declare that I have
examined the above taxpayer's return and accompanying schedules and statements, and to the best of my knowledge and belief, they are true, correct,
and complete. This declaration of Paid Preparer is based on all information of which the preparer has knowledge.
Check
if paid X Check
if self-
P00502613
ERO's ERO'S Signature Date preparer employed Your SSN or PTIN
Use KINDY & ELLIOTT
Only 310 N MAIN ST MALVERN AR 72104-2720 71-0777173
Firm's name and address FEIN
Under penalties of perjury, I declare that I have examined the above taxpayer's return and accompanying schedules and statements, and to the best of
my knowledge and belief, they are true, correct, and complete. This declaration is based on all information of which I have any knowledge.
Check
if self-
Paid Preparer's Signature Date employed Preparer's SSN or PTIN
Preparer's
Use Only
Firm's name and address FEIN
AR8453 (R 6/14/2021)
DAA
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Form 1040 Bank Account Verification 2021

Name Taxpayer Identification Number

CORY W & ASHLEY R GRIESEMER 324-52-3449

You have indicated that you would like to receive a refund via direct deposit or make a tax payment via electronic funds withdrawal (EFW)
from your bank account(s). Note that electronic funds can only be withdrawn from the primary account. Make sure sufficient funds are
available in the primary account. Per IRS Security Summit requirements, verify the name of financial institution, routing transit number,
account number, and type of account below. If there are any changes please make them on this form. Sign and date at the bottom to
indicate upon your review and verification that all account(s) listed are correct and return it to our office.

Primary Account
Name of Financial Institution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . BANK OZK
Routing Transit Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 082907273
Account Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21401080461
Type of Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CHECKING
Joint Account? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . NO

Secondary Account #1
Name of Financial Institution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Routing Transit Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Account Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Type of Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Joint Account? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Secondary Account #2
Name of Financial Institution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Routing Transit Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Account Number . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Type of Account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Joint Account? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Taxpayer Signature CORY W GRIESEMER Date

Spouse Signature ASHLEY R GRIESEMER Date

DO NOT SUBMIT THIS DOCUMENT TO IRS

21390 06/08/2022 9:25 AM

Kindy & Elliott

310 N Main St
Malvern, AR 72104-2720
501-337-7444

CORY W & ASHLEY R GRIESEMER

581 CRESTRIDGE DRIVE
MALVERN, AR 72104

Dear CORY & ASHLEY:

This letter is to confirm and specify the terms of our engagement with you and to clarify the
nature and extent of the services we will provide. In order to ensure an understanding of our
mutual responsibilities, we ask all clients for whom returns are prepared to confirm the following
arrangements.

We will prepare your 2021 federal and state income tax returns from information which you will
furnish to us. We will not audit or otherwise verify the data you submit, although it may be
necessary to ask you for clarification of some of the information. We will furnish you with
questionnaires and worksheets to guide you in gathering the necessary information. Your use of
such forms will assist in keeping the fee to a minimum.

It is your responsibility to provide all the information required for the preparation of complete
and accurate returns. You should retain all the documents, cancelled checks and other data that
form the basis of income and deductions. These may be necessary to prove the accuracy and
completeness of the returns to a taxing authority. You have the final responsibility for the income
tax returns and, therefore, you should review them carefully before you sign them.

Our work in connection with the preparation of your income tax returns does not include any
procedures designed to discover defalcations and/or irregularities, should any exist. We will
render such accounting and bookkeeping assistance as determined to be necessary for preparation
of the income tax returns.

The law provides various penalties that may be imposed when taxpayers understate their tax
liability. If you would like information on the amount or the circumstances of these penalties,
please contact us.

Your returns may be selected for review by the taxing authorities. Any proposed adjustments by
the examining agent are subject to certain rights of appeal. In the event of such government tax
examination, we will be available upon request to represent you and will render additional
invoices for the time and expenses incurred.

Our fee for these services will be based upon the amount of time required at standard billing rates
plus out-of-pocket expenses. All invoices are due and payable upon presentation.

If the foregoing fairly sets forth your understanding, please sign the enclosed copy of this letter
in the space indicated and return it to our office. However, if there are other tax returns you
expect us to prepare, please inform us by noting so at the end of the return copy of this letter.
21390 06/08/2022 9:25 AM

We want to express our appreciation for this opportunity to work with you.

Very truly yours,

Kindy & Elliott

Accepted By:

Date: