Form Student Loan


    Your Name:( * )

    E-mail:(*)

    Your Phone:( * )

    Home Phone:

    Social Security: ( * )

    DOB ( * )

    Full Address: ( * )

    House rent or owner Select: ( Rent or Owner )
    include_blank "Rent" "Owner"]

    Customer type: Select: ( New or Prior )

    Marital Status: Select: ( Single, Married, Divorced, Other )*

    Driver License:*

    Driver License State:*

    Driver License State Exp Date:* ( 12/12 = 1212 )*

    Retirement Plan?:Select: ( Yes or No )


    Student Loan information


    Studentloans.gov User: ( * )

    Studentloan.gov Password: ( * )

    Accept that all information is true and in good faith


    Client Privacy Statement and Consent for Disclosure of Information to a Third Party
    We value the trust you place in us when you share your personal information to provide you with our tax, insurance, credit, student loan and/or related financial services. The information we receive from you may include, but is not limited to, social security number, date of birth, marital status, source and amounts of income, deductions and taxes paid and payable, and information concerning your residence, dependents, pensions, medical deductions, and charitable contributions. This information is collected from you in written form, by phone, electronic, by mail and in personal interviews and consultations conducted by us, as well as by information we collect from other with your authorization. This form documents your request and gives us your permission to release the specified information to Fail Safe Insurance, Fail Safe Tax and Fail Safe Credit Specialist for marketing purposes. Our marketing campaigns are inclusive and not limited to Text Messages, Emails, Phone Calls and Direct Mail. Federal law requires this consent form be provided to you. Unless authorized by law, we cannot disclose your tax information to third parties for purposes other than the preparation of your tax return without your consent. If you consent to the disclosure of your tax return information, Federal law may not protect your tax return information from further use or distribution. You are not required to complete this form to engage our tax preparation services. If we obtain your signature on this form by conditioning our tax return preparation services on your consent, your consent will not be valid. If you agree to the disclosure of your tax return information, your consent is valid for the amount of time that you specify. If you do not specify the duration of your consent, your consent is valid for one year from the date of signature.
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    Your signature

    Walter QuesadaForm: Student Loan