CREDIT REPAIR CLIENT INTAKE FORM

Anderson Tax & Business Solutions

Please complete this secure credit intake form to begin your credit evaluation. Your information is encrypted and handled with the highest level of confidentiality.
Full Legal Name*

First NameMiddle NameLast NameSuffix
Date of Birth*

MonthDayYear
Date
Social Security Number (SSN) or ITIN*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
How did you hear about us?*

Social MediaReferralGoogleOther
What is your estimated credit score?*

300–499500–579580–669670–739740+Not sure
What are your main credit goals? (Select all)*

Increase credit scoreRemove negative itemsQualify for a homeQualify for business fundingBuild credit from scratch
Select all that apply to your credit report:*

Late PaymentsCollectionsCharge-offsRepossessionsBankruptciesForeclosuresStudent LoansJudgmentsIdentity Theft
Upload your credit report (if available)*

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Upload ID (Driver’s License or State ID)*

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Upload Proof of Address (Utility Bill, etc.)*

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Do you currently have active credit accounts?*

YesNo
If YES:

Credit CardsAuto LoansPersonal LoansOther
Employment Status*

EmployedSelf-EmployedUnemployedStudent
Monthly Income Range*

$0–$1,500$1,500–$3,000$3,000–$5,000$5,000+
What services are you interested in?*

Credit Repair OnlyCredit + Funding PreparationCredit + Tax Services Bundle
Have you worked with a credit repair company before?*

YesNo
Are you currently in bankruptcy?*

YesNo
CREDIT REPAIR DISCLOSURE:

I understand that credit repair results vary and no specific outcome is guaranteed. I authorize Anderson Tax & Business Solutions to review my credit profile for the purpose of improving my credit standing.
Do you agree to the terms?*
Type Yes or No
E-Signature: (You agree with terms)*
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Anderson Tax & Business Solutions