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Full Name:
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Cell Phone Number:
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Cell Phone Service Provider:
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Social Security:
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Email:
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Address: (please incl zip code)
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Date Of Birth:
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Occupation
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Upload Drivers License Photo:
Do you want to apply for Easy Advance* today? *Amounts vary up to $6,000.
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Yes
No
Did the primary taxpayer receive a Form 1095-A Health Insurance Marketplace Statement? (If you received a Form 1095-B or 1095-C it is not required to enter for 2024)
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Client Status:
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New Client
Returning Client
Filing Status:
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Single
Married Filing Joint
Married Filing Separate
Head Of Household
Spouse Full Name:
Spouse DOB:
Spouse Cell Phone:
Spouse Cell Phone Provider:
Spouse Social Security:
Do you have Dependents?
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Yes
No
Dependent(s) Name/DOB/ Social Security:(PLEASE PROVIDE PICTURE COPY OF SOCIAL SECURTY CARDS & BIRTH CERTIFICATE)
Upload Tax Documents: (W2's, 1099's, Driver's License/Valid ID, Utility Bill, Birth Certificate, SS Card, etc. )
By signing below, I certify all information is true and correct to the best of my knowledge.
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Date Submitted
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PREPARER
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Davonte
Bryan
Brent
Donna
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How did you hear about us?
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Notes: (OR self employment information)
Go to www.ontrackrefund.com or email us at info@ontrackrefund.com