If banking information is left blank, your refund check will be mailed.
____________________________
____________________________
____________________________
Checking
Bank Name
Routing Number
Account Number
Savings
Dependent Information
Relationship
College Student?
Name
SSN #
D.O.B.
Yes
No
Yes
No
Yes
No
Yes
No
Dependent's College
Dependent's Childcare Provider
Provider Name
College Name
Address
College Name
EIN / SSN #
Phone
Mother's Maiden Name
Dependent Name
Primary
Amount Paid
Spouse
The purpose of this form is to gather information to be used to prepare your tax return. All information is implicitedly protected and will not be used except for that
purpose. Applicant, by the use of this form, gives Tax Depot Financial Services permission to transmit the tax return to the IRS and/or EPS Financial.
If banking information is left blank, your refund check will be mailed.
____________________________
____________________________
____________________________
Checking
Bank Name
Routing Number
Account Number
Savings
Dependent Information
Relationship
College Student?
Name
SSN #
D.O.B.
Yes
No
Yes
No
Yes
No
Yes
No
Dependent's College
Dependent's Childcare Provider
Provider Name
College Name
Address
College Name
EIN / SSN #
Phone
Mother's Maiden Name
Dependent Name
Primary
Amount Paid
Spouse
The purpose of this form is to gather information to be used to prepare your tax return. All information is implicitedly protected and will not be used except for that
purpose. Applicant, by the use of this form, gives Tax Depot Financial Services permission to transmit the tax return to the IRS and/or EPS Financial.
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