Bank Product Application And Agreement (Application/agreement) - Louisville, Kentucky

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Republic Bank & Trust Company, 601 West Market Street, Louisville, Kentucky 40202
Bank Product Application and Agreement
(Application/Agreement)
INSTRUCTIONS: Joint Taxpayer information is required only if filing a joint tax return. IF YOU WANT TO APPLY FOR
AN EASY ADVANCE YOU MUST APPLY AS AN INDIVIDUAL EVEN IF YOU ARE MARRIED AND FILING JOINTLY.
ONLY ONE TAXPAYER CAN APPLY FOR AN EASY ADVANCE. Please refer to Section 5 for further information.
1. TAXPAYERS INFORMATION (Address must not be a P.O. Box)
Name: ______________________________________ Joint: ______________________________________
Address: _______________________________________________________________________________
2. WHICH BANK PRODUCT (S) ARE YOU APPLYING FOR?
 EASY ADVANCE LOAN: THE EASY ADVANCE IS A PRODUCT OFFERED BY REPUBLIC BANK & TRUST COMPANY (Republic) WHICH MAY BE
APPLIED FOR WITH OR WITHOUT RECEIVING A REFUND TRANSFER. I understand that by signing this Bank Product Application and Agreement I am
applying for a loan in the amount of ___________________. If filing a joint tax return, only one Taxpayer can apply for the Easy Advance and the Easy
Advance proceeds will be disbursed to the applying Taxpayer only. If I am applying for an Easy Advance and Refund Transfer, the Easy Advance proceeds
will be disbursed in accordance with Section 3 below. If I apply for an Easy Advance and Refund Transfer and my application for an Easy Advance is declined,
I understand that I will still receive a Refund Transfer. If I apply for an Easy Advance only (without the Refund Transfer), I understand that (i) the Easy Advance
Proceeds and remaining balance of my tax refund can only be disbursed via Direct Deposit or Xpress Refunds Prepaid Card (select one below) and (ii) the
remaining balance of my tax refund after repayment of the Easy Advance will be disbursed in the same manner as my Easy Advance.
 REFUND TRANSFER: I (which includes the joint taxpayer, if any) understand that by signing this Agreement, I am requesting and agreeing to receive my
federal and/or state tax refund(s), less the fees and payments set out in Section 4 below, by the disbursement method selected in Section 3 below. If filing a
joint tax return, the Refund Transfer check will be disbursed to both Taxpayers and the Refund Transfer direct deposit, prepaid card or Walmart Direct2Cash
will be disbursed in accordance with Section 3 below.
3. DISBURSEMENT METHOD: SELECT ONE THAT WILL APPLY TO THE PRODUCT(S) SELECTED IN SECTION 2 ABOVE.
 Direct Deposit: Republic will deposit funds directly to my bank account, as specified below (Bank Account).
Bank Routing Number: ____________________ Account Number: ____________________
 Checking  Savings
 Xpress Refunds Prepaid Card: Republic will deposit funds directly to my Xpress Refunds Prepaid Card (Card), with the Card issued to me by my tax
preparer. Please refer to the Card’s disclosures for all applicable fees, terms of use and further details.
 Issued at Tax Office - Customer Number: ___________________________________
 Mailed - Card will be mailed to the address provided in Section 1 and should be received in 7-10 business days.
 Walmart Direct2Cash: Republic will disburse funds at Walmart locations in the form of cash (Cash) for an additional one-time fee of $7.00. I will receive
instructions and a reference number via text and/or email to provide to Walmart in order to obtain the Cash.
 Check: Republic will disburse funds to me via check, printed by my tax preparer or mailed by Republic.
4. FEES: I understand that the Fees listed below are not due until tax preparation and any services provided to me in relation to the Refund Transfer (Services)
are complete. The Services are not complete until the earlier of (i) notification to me that the proceeds of my Refund Transfer are available or (ii) the 60
day
th
after my tax return has been e-filed with the IRS. The Refund Transfer Fee applies to the first refund received and an additional fee will be charged for each
subsequent funding received, whether federal or state.
Refund Transfer Fees
Tax Preparation Fees
Refund Transfer Fee paid to Republic:
$
Tax Preparation Fee paid to Tax Preparer:
$
Subsequent Funding Fee paid to Republic
$
Audit Fee paid to __________________:
$
Direct2Cash Fee paid to Republic:
$
Total Tax Preparation Fees:
$
Transmitter Fee paid to _________________:
$
Service Bureau Fee paid to ______________:
$
Total Refund Transfer Fees:
$
TOTAL FEES WITHHELD FROM REFUND: $
5. EASY ADVANCE SECURITY INTEREST IN REFUND. I, __________________________________, am not applying for, and will not be liable for
repayment of an Easy Advance. However, by signing below, as security for the Easy Advance for which my spouse has applied, I hereby authorize
and grant to Republic a security interest in the anticipated tax refund to be paid to me by the IRS and state taxing authority (if applicable) for the
2016 tax year.
6. ACKNOWLEDGEMENT/CERTIFICATION/AGREEMENT
By signing this Agreement in the spaces provided below, I do the following:
I acknowledge that (i) I am at least eighteen (18) years old, (ii) I received a completed copy of this Agreement, (iii) I have received, read, and understand
this Agreement, Republic’s Privacy Notice, a sheet entitled What You Need to Know Before Selecting a Bank Product, and all applicable state disclosures
and (iv) the Refund Transfer is not a loan or an extension of credit.
I certify that all my information contained in this Agreement is correct to the best of my knowledge, that this Agreement is based on my 2016 federal
and/or state income tax return(s) and that the tax return(s) are true, complete, and accurate in all respects.
I agree to all the terms and provisions set forth in this Agreement, including the WAIVER OF JURY TRIAL AND ARBITRATION section.
I authorize Republic to obtain my consumer credit report through any credit reporting agency.
I irrevocably authorize Republic to deduct from my federal and/or state tax refund the amount of any outstanding debt that I owe Republic.
x________________________________
__________
x________________________________
__________
Taxpayer Signature
Date
Joint Taxpayer Signature
Date
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