FINANCIAL REFRESH INTAKE FORM
This form secures your spot. Payment and activation of monitoring services is required to lock in your upgrade.
Are you able to maintain monthly monitoring services at $31.99 per month? - link will be provided after submission of this form.
*
Yes
No
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Intake Form - Please answer everything in its entirety! Do NOT skip any questions.
Are you a tax client of Rich Lifestyle Solutions?
*
Yes
No
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Referred By
First Name
Last Name
Reason/goals for credit repair
*
Have you ever used a credit repair company to dispute any accounts before?
*
Yes
No
Which program are you interested in?
*
3 month refresh
6 month refresh
Date
*
-
Month
-
Day
Year
Date
Signature
*
Plan Options
*
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( X )
3 Months
Please check your email for next steps.
$179.00
$
179.00
6 Months
Please check email for next steps.
$279.00
$
279.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
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