Business intake

Mailbox Request Form

PLEASE FILL OUT ALL INFORMATION APPLICABLE
Client Name*

First NameLast NameSuffix
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Valid Identification

Example: Government ID, Drivers License, Passport, Social Security Card, Birth Certificate
Cancelof
Home Address*

NO P O BOX/ PHYSICAL ADDRESS ONLY

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Name:
Type of Business
EIN if Available
DO YOU HAVE A BUSINESS? ANSWER THE QUESTION SPECIFIC TO YOUR BUSINESS ENTITY REGISTERED WITH THE SECRETARY OF STATE:*

YES (SOLE PROPRIETOR)YES (LLC)YES (S OR C CORP)YES (OTHER)NO
UPLOAD EIN, OR ARTICLE OF CORPORTATION PERTAINING TO YOUR BUSINESS.

Cancelof
This form is for intake purposes only!

Authorization for Direct Deposit
I authorize A R Financial LLC to make automatic withdrawals from my ACCOUNT(S)/ Credit/Debit/Card for mailbox rental fees.*

YesNo
AUTHORIZATION FOR WITHDRAWAL STATEMENT: I hereby authorize A R Financial LLC to initiate automatic withdrawals from my Account /Debit/Crediit at the financial institution named below.

I agree not to hold A R Financial LLC responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution.

This agreement will remain in effect until A R Financial LLC receives a written notice of cancellation from me or my financial institution, or until I submit a new/updated withdrawal form.
I agree to the above Authorization for Withdrawal Statement*

Yes, I agree
Card Payment Information

Subscription Choice

MonthlyBilled once a manth

$19.99 for each month

QuarterlyBilled every 3 months

$59.97 for each three months

Semi- AnnualBilled every 6 months

$119.94 for each six months

AnnualBilled once a year

$239.88 for each year

Subtotal

$0.00

Tax

$0.00

I WAS REFERRED BY:
I understand that this information is needed to process my request for assistance. AR Financial and/or A Tax Services will not be held liable for any associated penalties, audits, or fines as it relates to compliance.
Signature*

Clear
Date

MonthDayYear
Should be Empty:

Mailbox Request Form