Central Business Services, Inc. ~ Indianapolis, Indiana

8383 Craig Street, Suite 260, Indianapolis, Indiana 46250 ~ (888) 255-3939 ~ Fax: (317) 813-1009 ~ info@cbsitax.net

Please completely the form below. If you have questions, call us at (866) 255-3939 or e-mail us. If you would prefer, you can get a printable version of this form here.

Name:

E-Mail:

Married:

Social Security Number: - -

HOME ADDRESS

Street:

City:

State: Zip:

MAILING ADDRESS

(If different than Home Address)

Street:

City:

State: Zip:

PHONE NUMBERS

Home:

() -	Cell: () -

COMPANY INFORMATION

Name of Company Leased to:

Date Started (with this company):

TAX INFORMATION

Are you leasing or buying your vehicle?

If married, do you file your taxes jointly?

Number of dependents you claim on your tax return:
(Please do not include your spouse in this number if married)

VERY IMPORTANT

We will need a copy of your vehicle purchase or lease documents in order to provide an accurate P&L and tax projections. We will copy and return them to you.

AUTOMATIC WITHDRAW (ACH) or CREDIT CARD

Name:

Payment Method:

PAYMENT INFORMATION

I hereby authorize Central Business Services, Inc. (CBSI) to automatically withdraw or to automatically charge my debit/charge card for $80.00 each month for accounting and tax services.

Date of Monthly Charge/Withdraw:

PLEASE COMPLETE ONE OF THE FOLLOWING

AUTOMATIC WITHDRAW INFORMATION

Bank Name:
Address:
City:	State: Zip:
Routing #:	Account #:

DEBIT/CREDIT CARD INFORMATION

Credit/Debit Card #:
Expiration Date:

CVV Code (last 3 digits printed on signature strip on back of card):

RULE #1 – YOU ARE RUNNING A BUSINESS, NOT JUST DRIVING A TRUCK! CBSI CAN HELP!

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