Kaironeek Financial – ClientIntake Form (For Outsourcing Use)

Kaironeek Financial Secure Client Form
Client Basic Information
Full Legal Name

First NameLast Name
Date of Birth

MonthDayYear
Social Security Number (last4 digits)
Phone Number
Format: (000) 000-0000.
Email Address
Residential Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Identity Verification Documents
Upload Government-Issued ID (driver’s license or passport)

Cancelof
Upload Social Security Card

Cancelof
Upload Proof of Address

Cancelof
Credit Report Upload
Upload Full 3-Bureau Credit Report

Cancelof
CFPB Portal Credentials (Optional)

Only if the client has anaccount:
CFPB Username (optional) Username
CFPB Password (optional) Password
Note: We may request this later to assist with formal complaints
Referral Partner Company Info
Partner Business Name
Contact Person Full Name

First NameLast Name
Contact Person Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Person Email Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Monthly Volume
Company Website or Social Media (optional)
How did this client hear about your company? (optional)
Internal Client ID or Tracking Code (optional)
Client Case Notes (Optional)
Are there any specific issues to focus on (collections, late payments, inquiries, etc.)?
Authorization & Signature
I authorize Kaironeek Financial to perform credit dispute services on my behalf. I understand that communication will be with my referring company, and all updates will be provided through them.

I agree and authorize Kaironeek Financial to begin processing.
Typed Signature
Date

MonthDayYear
Should be Empty:

Kaironeek Financial Secure Client Form

Client Basic Information

Identity Verification Documents

Credit Report Upload

CFPB Portal Credentials (Optional)

Referral Partner Company Info

Client Case Notes (Optional)

Authorization & Signature