Bank Enrollment Form

Page 1

Your Name

Contact Phone Number

Email Address

Page 2

EFIN# if you have multiple numbers please list them here separately by comma. Ex. 00000, 00000, 00000, etc.

Company Name

Corporation Type (sole proprietor, partnership, LLC?)

EFIN Owner First Name

EFIN Owner Last Name

Page 3

EFIN Holder Title

EFIN Issued Address

EFIN Issued City, State, Zip

IRS Tracking Number (found on efile summary page)

Owner Office Phone Number

Owner Home Phone #

Owner Cell Phone #

Owner fax #

Email Address

Owner SSN

Date of Birth

Owner Photo ID State

Owner Photo ID # (drivers license)

Owner State Photo ID

Page 4

Owner Photo ID Expiration Date

What is your EFIN Registered Under? (EFIN or SSN)

Company EFIN (employer identification number)

Name of Financial Institution

Name of Deposit Account

Is this a Checking's or Savings account?

Routing Number

Account Number

Office Phone Number

Company Name (must be the same above)

Page 5

Cell Phone Number

Fax Number

Email Address

Office Manager's First Name

Office Manager's Last Name

Office Manager's e-mail Address

Office Manager's SSN

Office Manager's Date of Birth

# of years at current address

# of years e-filing

# of years with bank product's

# of Office Personnel

Where would you like your check mailed if a DD error occurs?

Page 6

Mail to

Mailing Address

City, State, Zip

Shipping Information

Ship To

Shipping Address (NO PO BOX)

City, State, Zip

Physical Address

Physical Address (NO PO BOX)

City, State, Zip

Page 7

Prior Year Bank (RA, EPS, TPG, etc)

Prior Year Efile Volume

Prior Year Funded Bank Products

Projected Bank Product Volume

Prior Year EFIN

Add on Fee (Additional Revenue Source)

Add-On Fee Net ($0.00-$78)

Service Bureau Add on Fee ($0.00-$99.00)

Fee Deposit Bank Account Type (Business or Personal)

Offer Advances/Loan's? (Yes/No)

Yes No

Offer Pre-ack loan's? (Yes/No)

Yes No

Offer Check Disbursement's? (Yes/No)

Yes No

Page 8

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Page 11

Have you been the subject of any fines, corrective actions or official orders related to violations of law or consumer compliance regulations relative to tax preparation or consumer lending? (Y/N)

Yes No

Before using any advertising or marketing of Bank Products, will you first receive approval from Refundo Bank? (Y/N)

Yes No

Bank Enrollment Form

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