Plugged In Tax Associates- Credit Repair Intake Form

Plugged In Tax Associates- Credit Repair Intake Form

All information provided is confidential and will be solely for credit evaluation and dispute purposes.
- Name
  
  First NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Social Security Number
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Email
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Have you lived at your current address for at least 2 years?
- Previous Address (if less than 2 years at current address)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Employment Status
- Employer Name
- Business Name
- Employer Identification Number
- Approximate Monthly Income
- What are you credit goals?
- Target Credit Score Goal
- Have you reviewed your credit report in the last 30 days?
- Credit Report (you can get a copy free from annualcreditreport.com)
  
  Cancelof
- Which credit bureaus show negative items? (select all that apply)
- Have you ever filed for bankruptcy?
- Year blanks* .
  Chapter Type a label*
- Do you have negative account you want removed or disputed?
- List accounts you want removed or disputed
  Please include creditor name, account type, balance and issue if knkown
- Unexpired Government Issues Identification
  
  Cancelof
- Social Security Card
  
  Cancelof
- Proof of Address (utility bill, bank statement, etc.)
  
  Cancelof
- I First Name Last Name authorize Plugged In Tax Associates to obtain, review, and dispute items on my credit report on my behalf.
  
  Signature Date
- Plugged In Tax Associates does not guarantee specific credit score increases. Results vary depending on individual credit profiles and creditor response.
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