Social Security Number *

Occupation

Address

License #

st

Issue Date

Exp Date

Spouse Name

Spouse Social Security Number

Date of Birth

Work Phone

Cell

Email Address

Occupation

Spouse Address

Spouse st

Spouse License #

Spouse Issue Date

Spouse Expiry Date

Describe Your Income

How Would You Like to Pay For Our Business

How Would You Like to Receive Your Refund?

Bank Name

Account Type

Routing #

Account #

How Did You Hear About Us?

Did You File Taxes Last Year?

Did You Bring A Copy Of Your Last Return?

Filing Status (choose one)

Will You Claim Any Dependents?

Dependent #1 Name

Dependent #1 Social Security Number

Dependent #1 Relationship

Dependent #1 Birth Date

Dependent #2 Name

Dependent #2 Social Security Number

Dependent #2 Relationship

Dependent #2 Birth Date

Dependent #3 Name

Dependent #3 Social Security Number

Dependent #3 Relationship

Dependent #3 Birth Date

Dependent #4 Name

Dependent #4 Social Security Number

Dependent #4 Realationship

Dependent #4 Birth Date

Would You Like To Apply For This Loan?

****This loan is not credit based. You will get approved or denied based on your tax refund. The minimum is $250 and the maximum is $7,000 **** (INTEREST AND BANK FEES APPLY) Apply for up to $1,000 interest free.

All information that I (Taxpayer) have provided on this client data form is true and accurate to the best of my knowledge.

All information that I (Spouse) have provided on this client data form is true and accurate to the best of my knowledge

Taxpayer Signature

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Spouse Signature

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Taxpayer Name

Business Owner Social or EIN

Business Name

Business Address

Business Cell

Business Phone

Describe Your Business

****This is not an all-inclusive listing. If you have other forms of documentation to support your business, please explain and submit copies of the documents.

All information that I(Taxpayer) have provided on this client data form is true and accurate to the best of my knowledge.

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Tax Payer Name

Tax Preparer

Date

CERTIFICATION OF SCHEDULE C

I, (Sign Below) attest that I have provided to the tax preparer is true and accurate. I also acknowledge that I will notify my tax preparer and/or any of its agents, owners and tax preparers harmless if any of the information that I’ve provided is found to be fraudulent or falsified. I am also certifying that I am a self-employed individual and I am aware that a Schedule C is being completed by the tax preparer with my permission and with my knowledge.

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Taxpayer's Name

Taxpayer's Signature

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Taxpayer SSN

Taxpayer Business Name

Tax Preparer Initials

Schedule C Reconstruct

Business Name

Business Address

Business Phone #

EIN #

BELOW, WRITE IN THE AMOUNT YOU MADE EACH MONTH

January

February

March

April

May

June

July

August

September

October

November

December

BELOW, WRITE IN THE AMOUNT OF EXPENSES THIS YEAR

Advertising

Office Expense

Rent

Utilities

Supplies

Taxes/Licenses

Labor/Wages

Misc./Other

Travel

Meals

Total Expenses

The information I have provided on this form is true and accurate to the best of my knowledge. (Sign Below)

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Taxpayer Signature

Clear

Date