Financial Information Request Form

* Indicates required fields.

Borrower Name Required: First * Middle Initial Required: Last *	Co-Borrower Name First Middle Initial Last

Primary Address Required: Street * Required: City, State, Zip *

Contact Required: Required: Home * Work/Cell Required: Required: Email *	Income Required: Household Gross * Self Employed Other Income Source (Spouse, Social Security, SSI, etc.)

Amount Owed Amount of Federal Tax Owed Amount of State Tax Owed Amount of Unsecured Debt (Credit Card, Medical, etc.)	Do you have any tax liens? Yes No Have you recently filed a bankruptcy? Yes No Is any of that debt past due? Yes No

Notes What are the circumstances that lead to the current situation/hardship? Additional Notes

Please complete all required fields.

Guidance Tax Relief, 8730 Wilshire Blvd #350, Beverly Hills, CA. 877-30GUIDE (877-304-8433) Tel: 310-228-1128 | Fax: 310-228-1129