Invoice: Angela Shackleford 2600 Poplar Ave Memphis TN 38112 (901) 247-4674

ANGELA SHACKLEFORD
2600 POPLAR AVE

MEMPHIS TN 38112
(901) 247-4674
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[BLAKE D WEBER ] Preparer No.: 995
[3650 DOGWOOD DR ] Client No. : XXX-XX-0727
[POWDER SPRINGS GA 30127 ] Invoice Date: 03/14/2023
[(404) 545-6279 ]

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INVOICE

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[PREPARATION OF 2022 FEDERAL/STATE FORMS & WORKSHEETS: [
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[FORM 1040 [
[FORM 1040 SCHEDULE 1 (ADDITIONAL INCOME AND ADJUSTMENTS) [
[FORM 1040 SCHEDULE 2 (ADDITIONAL TAXES) [
[FORM 1040 SCHEDULE 3 (ADDITIONAL CREDITS AND PAYMENTS) [
[SCHEDULE C (BUSINESS PROFIT/LOSS) [
[SCHEDULE H (HOUSEHOLD TAXES) [
[SCHEDULE SE (SELF-EMPLOYMENT TAX) [
[FORM W-2 (WAGES AND TAX) (2) [
[FORM 8879 (E-FILE SIGNATURE AUTHORIZATION) [
[FORM 8995 (QUALIFIED BUSINESS INCOME DEDUCTION - SIMPLIFIED) [
[GA STATE RESIDENT RETURN [
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[ These are charges for services rendered
[ Total Invoice [ $2,800.00 [
[ and do not include any Bank fees. [ [ [
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[ Amount Paid [ $0.00 [
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[ [ Balance Due [ $2,800.00 [
TAX YEAR: 2022 PROCESS DATE: 03/14/2023
OFFICE : Imperial Tax Services Corp
CLIENT : 259-77-0727 BLAKE D WEBER BIRTH DATE : 11/16/1988 Age:34
ADDRESS : 3650 DOGWOOD DR PREPARER : 995

: POWDER SPRINGS GA 30127
Home : (404) 545-6279 PREPARER FEE : 2,800.00

Work : ELECTRONIC :
Cell : TOTAL FEES : 2,800.00
STATUS : SINGLE
FED TYPE:
ST TYPE : Direct Deposit EFFECTIVE RATE: 24.98%
E-MAIL : Jaxweber8892@gmail.com
_____________________________________________________________________________________
LISTING OF FORMS FOR THIS RETURN
________________________________
FORM 1040
SCHEDULE 1 (ADDITIONAL INCOME AND ADJUSTMENTS TO INCOME)
SCHEDULE 2 (ADDITIONAL TAXES)
SCHEDULE 3 (ADDITIONAL CREDITS AND PAYMENTS)
FORM W-2
SCHEDULE C (BUSINESS INCOME)
SCHEDULE H (HOUSEHOLD EMPLOYMENT TAXES)
SCHEDULE SE (SELF EMPLOYMENT TAX)
FORM 8879 (E-FILE SIGNATURE AUTHORIZATION)
FORM 8995 (QUALIFIED BUSINESS INCOME DEDUCTION)
GA STATE RESIDENT RETURN
_____________________________________________________________________________________
* QUICK SUMMARY *
__________________________________________________________________________
SUMMARY FEDERAL GA RESIDENT
FILING STATUS 1 1
TOTAL INCOME 19736 0
TOTAL ADJUSTMENTS 266 0
ADJUSTED GROSS INCOME 19470 19470
DEDUCTIONS 12950 5400
EXEMPTIONS 0 2700
TAXABLE INCOME 5821 11370
TAX 583 481
CREDITS 0 5
OTHER TAXES 871 0
PAYMENTS 19949 529
REFUND 18495 53
AMOUNT DUE 0 0
CLIENT : BLAKE WEBER 259-77-0727
PREPARER : 995 DATE : 03/14/2023

_____________________________________________________________________________________
* W-2 INCOME FORMS SUMMARY *
_____________________________________________________________________________________
_________________________________________________________________________________
T/S EMPLOYER WAGES FED WITH FICA MED TAX STATE WITH ST
1. T BINSNESS LLC 9496 899 589 138 329 GA
2. T JL EXHIBIT SERVICES 6480 557 402 94 200 GA
TOTALS...... 15976 1456 991 232 529

a Employee’s social security number
259-77-0727 OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
47-2769653 9496 899
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
BINSNESS LLC 9496 589
1444 MUNICIPAL PKWY 5 Medicare wages and tips 6 Medicare tax withheld
DOUGLASVILLE GA 30134 9496 138
7 Social security tips 8 Allocated tips
d Control number 9 10 Dependent care benefits
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
BLAKE D WEBER d
e
13 Statutory Retirement Third-party 12b

3650 DOGWOOD DR employee plan sick pay C
o
POWDER SPRINGS GA 30127 d
e
14 Other 12c
C
o
d
e
12d
C
o
d
e
f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
GA 3193362YQ 9496 329
Form W-2 Wage and Tax Statement

a Employee’s social security number
2022 Department of the Treasury—Internal Revenue Service
259-77-0727 OMB No. 1545-0008

b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld
83-4494982 6480 557
c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld
JL EXHIBIT SERVICES 6480 402
PO BOX 155 5 Medicare wages and tips 6 Medicare tax withheld
MANDEVILLE LA 70470 6480 94
7 Social security tips 8 Allocated tips
d Control number 9 10 Dependent care benefits
e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a
C
o
BLAKE D WEBER d
e
13 Statutory Retirement Third-party 12b

3650 DOGWOOD DR employee plan sick pay C
o
POWDER SPRINGS GA 30127 d
e
14 Other 12c
C
o
d
e
12d
C
o
d
e
f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name
GA 1902950001 6480 200
Form W-2 Wage and Tax Statement 2022 Department of the Treasury—Internal Revenue Service
Tax Payer Due Diligence
Federal Disclosure
Federal law requires this consent form be provided to you ("you" refers to
each taxpayer, if more than one). Unless authorized by law, we cannot
disclose, without your consent, your tax return information to third parties
for purposes other than the preparation and filing of your tax return. 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 return
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.
I authorize ANGELA SHACKLEFORD:
Discretion-the freedom to decide what should be done in a particular

situation. "it is up to local authorities to use their discretion in setting
the charges
Taxpayer PIN: 10727
PIN Date 3/15/2023
Signature: ______________________________________________ Date: _______________
If you believe your tax return information has been disclosed or used
improperly in a manner unauthorized by law or without your permission, you
may contact the Treasury Inspector General for Tax Administration (TIGTA) by
telephone at 1-800-366-4484, or by email at complaints@tigta.treas.gov.
Tax Payer Due Diligence - 1 of 1

Form 8879 IRS e-file Signature Authorization
(Rev. January 2021) OMB No. 1545-0074
a
ERO must obtain and retain completed Form 8879.
Department of the Treasury
a Go to www.irs.gov/Form8879 for the latest information.
Internal Revenue Service
F
Submission Identification Number (SID)
Taxpayer’s name Social security number
BLAKE D WEBER 259-77-0727

Spouse’s name Spouse’s social security number
Part I Tax Return Information — Tax Year Ending December 31, 2022 (Enter year you are authorizing.)
Enter whole dollars only on lines 1 through 5.
Note: Form 1040-SS filers use line 4 only. Leave lines 1, 2, 3, and 5 blank.
1 Adjusted gross income . . . . . . . . . . . . . . . . . . . . . . . . . . 1 19470
2 Total tax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1454
3 Federal income tax withheld from Form(s) W-2 and Form(s) 1099 . . . . . . . . . . . . . 3 1456
4 Amount you want refunded to you . . . . . . . . . . . . . . . . . . . . . . 4 18495
5 Amount you owe . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Part II Taxpayer Declaration and Signature Authorization (Be sure you get and keep a copy of your return)
Under penalties of perjury, I declare that I have examined a copy of the income tax return (original or amended) I am now authorizing, and to the best of
my knowledge and belief, it is true, correct, and complete. I further declare that the amounts in Part I above are the amounts from the income tax
return (original or amended) I am now authorizing. I consent to allow my intermediate service provider, transmitter, or electronic return originator (ERO)
to send my return to the IRS and to receive from the IRS (a) an acknowledgement of receipt or reason for rejection of the transmission, (b) the reason
for any delay in processing the return or refund, and (c) the date of any refund. If applicable, I authorize the U.S. Treasury and its designated Financial
Agent to initiate an ACH electronic funds withdrawal (direct debit) entry to the financial institution account indicated in the tax preparation software for
payment of my federal taxes owed on this return and/or a payment of estimated tax, and the financial institution to debit the entry to this account. This
authorization is to remain in full force and effect until I notify the U.S. Treasury Financial Agent to terminate the authorization. To revoke (cancel) a
payment, I must contact the U.S. Treasury Financial Agent at 1-888-353-4537. Payment cancellation requests must be received no later than 2
business days prior to the payment (settlement) date. I also authorize the financial institutions involved in the processing of the electronic payment of
taxes to receive confidential information necessary to answer inquiries and resolve issues related to the payment. I further acknowledge that the
personal identification number (PIN) below is my signature for the income tax return (original or amended) I am now authorizing and, if applicable, my
Electronic Funds Withdrawal Consent.
Taxpayer’s PIN: check one box only
1 0 7 2 7
X I authorize ANGELA SHACKLEFORD to enter or generate my PIN as my
Enter five digits, but
ERO firm name don’t enter all zeros
signature on the income tax return (original or amended) I am now authorizing.
I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.
Your signature a Date a 03/14/2023
Spouse’s PIN: check one box only

I authorize to enter or generate my PIN as my
ERO firm name Enter five digits, but
signature on the income tax return (original or amended) I am now authorizing. don’t enter all zeros
I will enter my PIN as my signature on the income tax return (original or amended) I am now authorizing. Check this box only
if you are entering your own PIN and your return is filed using the Practitioner PIN method. The ERO must complete Part III
below.
Spouse’s signature a Date a

Practitioner PIN Method Returns Only—continue below
Part III Certification and Authentication — Practitioner PIN Method Only
ERO’s EFIN/PIN. Enter your six-digit EFIN followed by your five-digit self-selected PIN. 6 2 1 4 6 6 2 3 2 3 6
Don’t enter all zeros
I certify that the above numeric entry is my PIN, which is my signature for the electronic individual income tax return (original or amended) I am now
authorized to file for tax year indicated above for the taxpayer(s) indicated above. I confirm that I am submitting this return in accordance with the
requirements of the Practitioner PIN method and Pub. 1345, Handbook for Authorized IRS e-file Providers of Individual Income Tax Returns.
ERO’s signature a 03/14/2023 Date a

ERO Must Retain This Form — See Instructions
Don’t Submit This Form to the IRS Unless Requested To Do So
For Paperwork Reduction Act Notice, see your tax return instructions. Pso7020
Form 8879 (Rev. 01-2021)
QNA
1040 U.S. Individual Income Tax Return 2022
Form Department of the Treasury—Internal Revenue Service
OMB No. 1545-0074 IRS Use Only—Do not write or staple in this space.
Filing Status x Single Married filing jointly Married filing separately (MFS) Head of household (HOH)
Qualifying surviving
Check only spouse (QSS)
one box. If you checked the MFS box, enter the name of your spouse. If you checked the HOH or QSS box, enter the child’s name if the qualifying
person is a child but not your dependent:
Your first name and middle initial Last name Your social security number
If joint return, spouse’s first name and middle initial Last name Spouse’s social security number
Home address (number and street). If you have a P.O. box, see instructions. Apt. no. Presidential Election Campaign
3650 DOGWOOD DR Check here if you, or your
spouse if filing jointly, want $3
City, town, or post office. If you have a foreign address, also complete spaces below. State ZIP code
to go to this fund. Checking a
POWDER SPRINGS GA 30127 box below will not change
Foreign country name Foreign province/state/county Foreign postal code your tax or refund.
You Spouse
Digital At any time during 2022, did you: (a) receive (as a reward, award, or payment for property or services); or (b) sell,
Assets exchange, gift, or otherwise dispose of a digital asset (or a financial interest in a digital asset)? (See instructions.) Yes X No
Standard Someone can claim: You as a dependent Your spouse as a dependent
Deduction Spouse itemizes on a separate return or you were a dual-status alien
Age/Blindness You: Were born before January 2, 1958 Are blind Spouse: Was born before January 2, 1958 Is blind
Dependents (see instructions): (2) Social security (3) Relationship (4) Check the box if qualifies for (see instructions):
(1) First name Last name number to you Child tax credit Credit for other dependents
If more
than four
dependents,
see instructions
and check
here . .
1a Total amount from Form(s) W-2, box 1 (see instructions) . . . . . . . . . . . . . 1a 15976
Income
b Household employee wages not reported on Form(s) W-2 . . . . . . . . . . . . . 1b
Attach Form(s) c Tip income not reported on line 1a (see instructions) . . . . . . . . . . . . . . 1c
W-2 here. Also
attach Forms d Medicaid waiver payments not reported on Form(s) W-2 (see instructions) . . . . . . . . 1d
W-2G and e Taxable dependent care benefits from Form 2441, line 26 . . . . . . . . . . . . 1e
1099-R if tax
was withheld. f Employer-provided adoption benefits from Form 8839, line 29 . . . . . . . . . . . 1f
If you did not g Wages from Form 8919, line 6 . . . . . . . . . . . . . . . . . . . . . 1g
get a Form h Other earned income (see instructions) . . . . . . . . . . . . . . . . . . 1h
W-2, see
instructions.
i Nontaxable combat pay election (see instructions) . . . . . . . 1i
z Add lines 1a through 1h . . . . . . . . . . . . . . . . . . . . . . 1z 15976
Attach Sch. B 2a Tax-exempt interest . . . 2a b Taxable interest . . . . . 2b
if required. 3a Qualified dividends . . . 3a b Ordinary dividends . . . . . 3b
4a IRA distributions . . . . 4a b Taxable amount . . . . . . 4b
Standard 5a Pensions and annuities . . 5a b Taxable amount . . . . . . 5b
Deduction for—
6a Social security benefits . . 6a b Taxable amount . . . . . . 6b
• Single or
Married filing c If you elect to use the lump-sum election method, check here (see instructions) . . . . .
separately,
$12,950 7 Capital gain or (loss). Attach Schedule D if required. If not required, check here . . . . . 7
• Married filing 8 Other income from Schedule 1, line 10 . . . . . . . . . . . . . . . . . . 8 3760
jointly or
Qualifying 9 Add lines 1z, 2b, 3b, 4b, 5b, 6b, 7, and 8. This is your total income . . . . . . . . . . 9 19736
surviving spouse, 266
$25,900
10 Adjustments to income from Schedule 1, line 26 . . . . . . . . . . . . . . . 10
• Head of 11 Subtract line 10 from line 9. This is your adjusted gross income . . . . . . . . . . 11 19470
household,
$19,400 12 Standard deduction or itemized deductions (from Schedule A) . . . . . . . . . . 12 12950
• If you checked 13 Qualified business income deduction from Form 8995 or Form 8995-A . . . . . . . . . 13 699
any box under
Standard 14 Add lines 12 and 13 . . . . . . . . . . . . . . . . . . . . . . . . 14 13649
Deduction, 15 Subtract line 14 from line 11. If zero or less, enter -0-. This is your taxable income . . . . . 5821
see instructions.
15
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions. Form 1040 (2022)
QNA
WEBER 259-77-0727
Form 1040 (2022) Page 2
Tax and 16 Tax (see instructions). Check if any from Form(s): 1 8814 2 4972 3 . . 16 583
Credits 17 Amount from Schedule 2, line 3 . . . . . . . . . . . . . . . . . . . . 17
18 Add lines 16 and 17 . . . . . . . . . . . . . . . . . . . . . . . . 18 583
19 Child tax credit or credit for other dependents from Schedule 8812 . . . . . . . . . . 19
20 Amount from Schedule 3, line 8 . . . . . . . . . . . . . . . . . . . . 20
21 Add lines 19 and 20 . . . . . . . . . . . . . . . . . . . . . . . . 21
22 Subtract line 21 from line 18. If zero or less, enter -0- . . . . . . . . . . . . . . 22 583
23 Other taxes, including self-employment tax, from Schedule 2, line 21 . . . . . . . . . 23 871
24 Add lines 22 and 23. This is your total tax . . . . . . . . . . . . . . . . . 24 1454
Payments 25 Federal income tax withheld from:
a Form(s) W-2 . . . . . . . . . . . . . . . . . . 25a 1456
b Form(s) 1099 . . . . . . . . . . . . . . . . . . 25b
c Other forms (see instructions) . . . . . . . . . . . . . 25c
d Add lines 25a through 25c . . . . . . . . . . . . . . . . . . . . . . 25d 1456
26 2022 estimated tax payments and amount applied from 2021 return . . . . . . . . . . 26
If you have a
qualifying child, 27 Earned income credit (EIC) . . . . . . . . . . . . . . 27
attach Sch. EIC.
28 Additional child tax credit from Schedule 8812 . . . . . . . . 28
29 American opportunity credit from Form 8863, line 8 . . . . . . . 29
30 Reserved for future use . . . . . . . . . . . . . . . 30
31 Amount from Schedule 3, line 15 . . . . . . . . . . . . 31 18493
32 Add lines 27, 28, 29, and 31. These are your total other payments and refundable credits . . 32 18493
33 Add lines 25d, 26, and 32. These are your total payments . . . . . . . . . . . . 33 19949
Refund 34 If line 33 is more than line 24, subtract line 24 from line 33. This is the amount you overpaid . . 34 18495
35a Amount of line 34 you want refunded to you. If Form 8888 is attached, check here . . . . 35a 18495
Direct deposit? b Routing number 1 2 5 1 0 9 0 1 9 c Type: X Checking Savings
See instructions.
d Account number 8 7 5 1 0 3 6 7 3 5 3 4
36 Amount of line 34 you want applied to your 2023 estimated tax . . . 36
Amount 37 Subtract line 33 from line 24. This is the amount you owe.
You Owe For details on how to pay, go to www.irs.gov/Payments or see instructions . . . . . . . . 37
38 Estimated tax penalty (see instructions) . . . . . . . . . . 38
Third Party Do you want to allow another person to discuss this return with the IRS? See
Designee instructions . . . . . . . . . . . . . . . . . . . . . X Yes. Complete below. No
Designee’s Phone Personal identification
name ALEXIS BEAN no. 901-247-4674 number (PIN) 2 3 2 3 6
Under penalties of perjury, I declare that I have examined this return and accompanying schedules and statements, and to the best of my knowledge and
Sign belief, they are true, correct, and complete. Declaration of preparer (other than taxpayer) is based on all information of which preparer has any knowledge.
Here Your signature Date Your occupation If the IRS sent you an Identity
Protection PIN, enter it here
(see inst.)
Joint return? 03/14/23 TRAVEL BARBER 152819
See instructions. Spouse’s signature. If a joint return, both must sign. Date Spouse’s occupation If the IRS sent your spouse an
Keep a copy for Identity Protection PIN, enter it here
your records. (see inst.)
Phone no. (404) 545-6279 Email address Jaxweber8892@gmail.com

Preparer’s name Preparer’s signature Date PTIN Check if:
Paid 03/14/23 Self-employed
ALEXIS BEAN P03031941
Preparer
Firm’s name Imperial Tax Services Corp Phone no. 901-247-4674
Use Only
Firm’s address 2600 POPLAR AVE MEMPHIS TN 38112 Firm’s EIN 84-3927262
Go to www.irs.gov/Form1040 for instructions and the latest information. Form 1040 (2022)
QNA
SCHEDULE 1 OMB No. 1545-0074
Additional Income and Adjustments to Income
(Form 1040)
Attach to Form 1040, 1040-SR, or 1040-NR. 2022
Attachment
Go to www.irs.gov/Form1040 for instructions and the latest information.
Internal Revenue Service Sequence No. 01
Name(s) shown on Form 1040, 1040-SR, or 1040-NR Your social security number
BLAKE WEBER 259-77-0727
Part I Additional Income
1 Taxable refunds, credits, or offsets of state and local income taxes . . . . . . . . . 1
2a Alimony received . . . . . . . . . . . . . . . . . . . . . . . . . . . 2a
b Date of original divorce or separation agreement (see instructions):
3 Business income or (loss). Attach Schedule C . . . . . . . . . . . . . . . . . 3 3760
4 Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . . . . . . . 4
5 Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E . 5
6 Farm income or (loss). Attach Schedule F . . . . . . . . . . . . . . . . . . . 6
7 Unemployment compensation . . . . . . . . . . . . . . . . . . . . . . . 7
8 Other income:
a Net operating loss . . . . . . . . . . . . . . . . . . . 8a ( )
b Gambling . . . . . . . . . . . . . . . . . . . . . . 8b
c Cancellation of debt . . . . . . . . . . . . . . . . . . 8c
d Foreign earned income exclusion from Form 2555 . . . . . . . 8d ( )
e Income from Form 8853 . . . . . . . . . . . . . . . . . 8e
f Income from Form 8889 . . . . . . . . . . . . . . . . . 8f
g Alaska Permanent Fund dividends . . . . . . . . . . . . . 8g
h Jury duty pay . . . . . . . . . . . . . . . . . . . . . 8h
i Prizes and awards . . . . . . . . . . . . . . . . . . . 8i
j Activity not engaged in for profit income . . . . . . . . . . . 8j
k Stock options . . . . . . . . . . . . . . . . . . . . . 8k
l Income from the rental of personal property if you engaged in the rental
for profit but were not in the business of renting such property . . . 8l
m Olympic and Paralympic medals and USOC prize money (see
instructions) . . . . . . . . . . . . . . . . . . . . . 8m
n Section 951(a) inclusion (see instructions) . . . . . . . . . . 8n
o Section 951A(a) inclusion (see instructions) . . . . . . . . . . 8o
p Section 461(l) excess business loss adjustment . . . . . . . . 8p
q Taxable distributions from an ABLE account (see instructions) . . . 8q
r Scholarship and fellowship grants not reported on Form W-2 . . . 8r
s Nontaxable amount of Medicaid waiver payments included on Form
1040, line 1a or 1d . . . . . . . . . . . . . . . . . . . 8s ( )
t Pension or annuity from a nonqualifed deferred compensation plan or
a nongovernmental section 457 plan . . . . . . . . . . . . 8t
u Wages earned while incarcerated . . . . . . . . . . . . . 8u
z Other income. List type and amount:
8z
9 Total other income. Add lines 8a through 8z . . . . . . . . . . . . . . . . . . 9
10 Combine lines 1 through 7 and 9. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 8 10 3760
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule 1 (Form 1040) 2022
QNA
Schedule 1 (Form 1040) 2022 Page 2
Part II Adjustments to Income

11 Educator expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
12 Certain business expenses of reservists, performing artists, and fee-basis government
officials. Attach Form 2106 . . . . . . . . . . . . . . . . . . . . . . . . 12
13 Health savings account deduction. Attach Form 8889 . . . . . . . . . . . . . . 13
14 Moving expenses for members of the Armed Forces. Attach Form 3903 . . . . . . . 14
15 Deductible part of self-employment tax. Attach Schedule SE . . . . . . . . . . . 15 266
16 Self-employed SEP, SIMPLE, and qualified plans . . . . . . . . . . . . . . . . 16
17 Self-employed health insurance deduction . . . . . . . . . . . . . . . . . . 17
18 Penalty on early withdrawal of savings . . . . . . . . . . . . . . . . . . . . 18
19a Alimony paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19a
b Recipient’s SSN . . . . . . . . . . . . . . . . . . . . . .
c Date of original divorce or separation agreement (see instructions):
20 IRA deduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
21 Student loan interest deduction . . . . . . . . . . . . . . . . . . . . . . 21
22 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . . 22
23 Archer MSA deduction . . . . . . . . . . . . . . . . . . . . . . . . . 23
24 Other adjustments:
a Jury duty pay (see instructions) . . . . . . . . . . . . . . 24a
b Deductible expenses related to income reported on line 8l from the
rental of personal property engaged in for profit . . . . . . . . 24b
c Nontaxable amount of the value of Olympic and Paralympic medals
and USOC prize money reported on line 8m . . . . . . . . . . 24c
d Reforestation amortization and expenses . . . . . . . . . . . 24d
e Repayment of supplemental unemployment benefits under the Trade
Act of 1974 . . . . . . . . . . . . . . . . . . . . . . 24e
f Contributions to section 501(c)(18)(D) pension plans . . . . . . . 24f
g Contributions by certain chaplains to section 403(b) plans . . . . 24g
h Attorney fees and court costs for actions involving certain unlawful
discrimination claims (see instructions) . . . . . . . . . . . . 24h
i Attorney fees and court costs you paid in connection with an award
from the IRS for information you provided that helped the IRS detect
tax law violations . . . . . . . . . . . . . . . . . . . 24i
j Housing deduction from Form 2555 . . . . . . . . . . . . . 24j
k Excess deductions of section 67(e) expenses from Schedule K-1 (Form
1041) . . . . . . . . . . . . . . . . . . . . . . . . 24k
z Other adjustments. List type and amount:
24z
25 Total other adjustments. Add lines 24a through 24z . . . . . . . . . . . . . . . 25
26 Add lines 11 through 23 and 25. These are your adjustments to income. Enter here and on
Form 1040 or 1040-SR, line 10, or Form 1040-NR, line 10a . . . . . . . . . . . . 26 266
Schedule 1 (Form 1040) 2022
QNA
Additional Taxes
(Form 1040)
Attach to Form 1040, 1040-SR, or 1040-NR. 2022
Attachment
Part I Tax
1 Alternative minimum tax. Attach Form 6251 . . . . . . . . . . . . . . . . 1
2 Excess advance premium tax credit repayment. Attach Form 8962 . . . . . . . 2
3 Add lines 1 and 2. Enter here and on Form 1040, 1040-SR, or 1040-NR, line 17 . . 3
Part II Other Taxes
4 Self-employment tax. Attach Schedule SE . . . . . . . . . . . . . . . . . 4 532
5 Social security and Medicare tax on unreported tip income.
Attach Form 4137 . . . . . . . . . . . . . . . . . . 5
6 Uncollected social security and Medicare tax on wages. Attach
Form 8919 . . . . . . . . . . . . . . . . . . . . . 6
7 Total additional social security and Medicare tax. Add lines 5 and 6 . . . . . . 7
8 Additional tax on IRAs or other tax-favored accounts. Attach Form 5329 if required.
If not required, check here . . . . . . . . . . . . . . . . . . . . . 8
9 Household employment taxes. Attach Schedule H . . . . . . . . . . . . . 9 339
10 Repayment of first-time homebuyer credit. Attach Form 5405 if required . . . . . 10
11 Additional Medicare Tax. Attach Form 8959 . . . . . . . . . . . . . . . . 11
12 Net investment income tax. Attach Form 8960 . . . . . . . . . . . . . . . 12
13 Uncollected social security and Medicare or RRTA tax on tips or group-term life
insurance from Form W-2, box 12 . . . . . . . . . . . . . . . . . . . . 13
14 Interest on tax due on installment income from the sale of certain residential lots
and timeshares . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
15 Interest on the deferred tax on gain from certain installment sales with a sales price
over $150,000 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
16 Recapture of low-income housing credit. Attach Form 8611 . . . . . . . . . . 16
(continued on page 2)
QNA
Part II Other Taxes (continued)

17 Other additional taxes:
a Recapture of other credits. List type, form number, and amount:
17a
b Recapture of federal mortgage subsidy, if you sold your home
see instructions . . . . . . . . . . . . . . . . . . . 17b
c Additional tax on HSA distributions. Attach Form 8889 . . . . 17c
d Additional tax on an HSA because you didn’t remain an eligible
individual. Attach Form 8889 . . . . . . . . . . . . . . 17d
e Additional tax on Archer MSA distributions. Attach Form 8853 . 17e
f Additional tax on Medicare Advantage MSA distributions. Attach
Form 8853 . . . . . . . . . . . . . . . . . . . . . 17f
g Recapture of a charitable contribution deduction related to a
fractional interest in tangible personal property . . . . . . . 17g
h Income you received from a nonqualified deferred compensation
plan that fails to meet the requirements of section 409A . . . 17h
i Compensation you received from a nonqualified deferred
compensation plan described in section 457A . . . . . . . 17i
j Section 72(m)(5) excess benefits tax . . . . . . . . . . . 17j
k Golden parachute payments . . . . . . . . . . . . . . 17k
l Tax on accumulation distribution of trusts . . . . . . . . . 17l
m Excise tax on insider stock compensation from an expatriated
corporation . . . . . . . . . . . . . . . . . . . . . 17m
n Look-back interest under section 167(g) or 460(b) from Form
8697 or 8866 . . . . . . . . . . . . . . . . . . . . 17n
o Tax on non-effectively connected income for any part of the
year you were a nonresident alien from Form 1040-NR . . . . 17o
p Any interest from Form 8621, line 16f, relating to distributions
from, and dispositions of, stock of a section 1291 fund . . . . 17p
q Any interest from Form 8621, line 24 . . . . . . . . . . . 17q
z Any other taxes. List type and amount:
17z
18 Total additional taxes. Add lines 17a through 17z . . . . . . . . . . . . . . 18
19 Reserved for future use . . . . . . . . . . . . . . . . . . . . . . . . 19
20 Section 965 net tax liability installment from Form 965-A . . . 20
21 Add lines 4, 7 through 16, and 18. These are your total other taxes. Enter here and
on Form 1040 or 1040-SR, line 23, or Form 1040-NR, line 23b . . . . . . . . . 21 871
Schedule 2 (Form 1040) 2022
QNA
Additional Credits and Payments
2022
(Form 1040)
Attach to Form 1040, 1040-SR, or 1040-NR.
Department of the Treasury Attachment
Part I Nonrefundable Credits
1 Foreign tax credit. Attach Form 1116 if required . . . . . . . . . . . . . . 1
2 Credit for child and dependent care expenses from Form 2441, line 11. Attach
Form 2441 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Education credits from Form 8863, line 19 . . . . . . . . . . . . . . . . . 3
4 Retirement savings contributions credit. Attach Form 8880 . . . . . . . . . . 4
5 Residential energy credits. Attach Form 5695 . . . . . . . . . . . . . . . 5
6 Other nonrefundable credits:
a General business credit. Attach Form 3800 . . . . . . . . 6a
b Credit for prior year minimum tax. Attach Form 8801 . . . . 6b
c Adoption credit. Attach Form 8839 . . . . . . . . . . . . 6c
d Credit for the elderly or disabled. Attach Schedule R . . . . . 6d
e Alternative motor vehicle credit. Attach Form 8910 . . . . . 6e
f Qualified plug-in motor vehicle credit. Attach Form 8936 . . . 6f
g Mortgage interest credit. Attach Form 8396 . . . . . . . . 6g
h District of Columbia first-time homebuyer credit. Attach Form 8859 6h
i Qualified electric vehicle credit. Attach Form 8834 . . . . . 6i
j Alternative fuel vehicle refueling property credit. Attach Form 8911 6j
k Credit to holders of tax credit bonds. Attach Form 8912 . . . 6k
l Amount on Form 8978, line 14. See instructions . . . . . . 6l
z Other nonrefundable credits. List type and amount:
6z
7 Total other nonrefundable credits. Add lines 6a through 6z . . . . . . . . . . 7
8 Add lines 1 through 5 and 7. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 20 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
(continued on page 2)
QNA
Part II Other Payments and Refundable Credits

9 Net premium tax credit. Attach Form 8962 . . . . . . . . . . . . . . . . . 9
10 Amount paid with request for extension to file (see instructions) . . . . . . . . 10
11 Excess social security and tier 1 RRTA tax withheld . . . . . . . . . . . . . 11
12 Credit for federal tax on fuels. Attach Form 4136 . . . . . . . . . . . . . . 12
13 Other payments or refundable credits:
a Form 2439 . . . . . . . . . . . . . . . . . . . . . 13a
b Credit for qualified sick and family leave wages paid in 2022 from
Schedule(s) H for leave taken before April 1, 2021 . . . . . . 13b 9004
c Reserved for future use . . . . . . . . . . . . . . . . 13c
d Credit for repayment of amounts included in income from earlier
years . . . . . . . . . . . . . . . . . . . . . . . . 13d
e Reserved for future use . . . . . . . . . . . . . . . . 13e
f Deferred amount of net 965 tax liability (see instructions) . . . 13f
g Reserved for future use . . . . . . . . . . . . . . . . 13g
h Credit for qualified sick and family leave wages paid in 2022
from Schedule(s) H for leave taken after March 31, 2021, and
before October 1, 2021 . . . . . . . . . . . . . . . . 13h 9489
z Other payments or refundable credits. List type and amount:
13z
14 Total other payments or refundable credits. Add lines 13a through 13z . . . . . 14 18493
15 Add lines 9 through 12 and 14. Enter here and on Form 1040, 1040-SR, or 1040-NR,
line 31 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 18493
QNA Schedule 3 (Form 1040) 2022
SCHEDULE C Profit or Loss From Business OMB No. 1545-0074
2022
(Form 1040) (Sole Proprietorship)
Go to www.irs.gov/ScheduleC for instructions and the latest information.
Attachment
Internal Revenue Service Attach to Form 1040, 1040-SR, 1040-NR, or 1041; partnerships must generally file Form 1065. Sequence No. 09
Name of proprietor Link:1000 Social security number (SSN)
A Principal business or profession, including product or service (see instructions) B Enter code from instructions
BARBER SHOPS 8 1 2 1 1 1
C Business name. If no separate business name, leave blank. D Employer ID number (EIN) (see instr.)
8 8 4 3 0 7 2 7 7
E Business address (including suite or room no.) 3650 DOGWOOD DR
City, town or post office, state, and ZIP code POWDER SPRINGS GA 30127
F Accounting method: (1) X Cash (2) Accrual (3) Other (specify)
G Did you “materially participate” in the operation of this business during 2022? If “No,” see instructions for limit on losses . X Yes No
H If you started or acquired this business during 2022, check here . . . . . . . . . . . . . . . . . .
I Did you make any payments in 2022 that would require you to file Form(s) 1099? See instructions . . . . . . . . Yes X No
J If “Yes,” did you or will you file required Form(s) 1099? . . . . . . . . . . . . . . . . . . . . . Yes No
Part I Income
1 Gross receipts or sales. See instructions for line 1 and check the box if this income was reported to you on
Form W-2 and the “Statutory employee” box on that form was checked . . . . . . . . . 1
2 Returns and allowances . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 Subtract line 2 from line 1 . . . . . . . . . . . . . . . . . . . . . . . . 3
4 Cost of goods sold (from line 42) . . . . . . . . . . . . . . . . . . . . . . 4
5 Gross profit. Subtract line 4 from line 3 . . . . . . . . . . . . . . . . . . . . 5
6 Other income, including federal and state gasoline or fuel tax credit or refund (see instructions) . . . . 6 29300
7 Gross income. Add lines 5 and 6 . . . . . . . . . . . . . . . . . . . . . . 7 29300
Part II Expenses. Enter expenses for business use of your home only on line 30.
8 Advertising . . . . . 8 7795 18 Office expense (see instructions) . 18
9 Car and truck expenses 19 Pension and profit-sharing plans . 19
(see instructions) . . . 9 20 Rent or lease (see instructions):
10 Commissions and fees . 10 a Vehicles, machinery, and equipment 20a
11 Contract labor (see instructions) 11 b Other business property . . . 20b
12 Depletion . . . . . 12 21 Repairs and maintenance . . . 21 2009
13 Depreciation and section 179 22 Supplies (not included in Part III) . 22 5150
expense deduction (not
included in Part III) (see 23 Taxes and licenses . . . . . 23
instructions) . . . . 13 24 Travel and meals:
14 Employee benefit programs a Travel . . . . . . . . . 24a
(other than on line 19) . 14 b Deductible meals (see
15 Insurance (other than health) 15 3780 instructions) . . . . . . . 24b
16 Interest (see instructions): 25 Utilities . . . . . . . . 25 3478
a Mortgage (paid to banks, etc.) 16a 26 Wages (less employment credits) 26
b Other . . . . . . 16b 27a Other expenses (from line 48) . . 27a 2928
17 Legal and professional services 17 400 b Reserved for future use . . . 27b
28 Total expenses before expenses for business use of home. Add lines 8 through 27a . . . . . . . 28 25540
29 Tentative profit or (loss). Subtract line 28 from line 7 . . . . . . . . . . . . . . . . . 29 3760
30 Expenses for business use of your home. Do not report these expenses elsewhere. Attach Form 8829
unless using the simplified method. See instructions.
Simplified method filers only: Enter the total square footage of (a) your home:
and (b) the part of your home used for business: . Use the Simplified
Method Worksheet in the instructions to figure the amount to enter on line 30 . . . . . . . . . 30
}
31 Net profit or (loss). Subtract line 30 from line 29.
• If a profit, enter on both Schedule 1 (Form 1040), line 3, and on Schedule SE, line 2. (If you
checked the box on line 1, see instructions.) Estates and trusts, enter on Form 1041, line 3. 31 3760
• If a loss, you must go to line 32.
}
32 If you have a loss, check the box that describes your investment in this activity. See instructions.
• If you checked 32a, enter the loss on both Schedule 1 (Form 1040), line 3, and on Schedule
SE, line 2. (If you checked the box on line 1, see the line 31 instructions.) Estates and trusts, enter on 32a All investment is at risk.
Form 1041, line 3. 32b Some investment is not
• If you checked 32b, you must attach Form 6198. Your loss may be limited. at risk.
For Paperwork Reduction Act Notice, see the separate instructions. Schedule C (Form 1040) 2022
QNA
BLAKE D WEBER Link:1000 259-77-0727
Schedule C (Form 1040) 2022 Page 2
Part III Cost of Goods Sold (see instructions)
33 Method(s) used to
value closing inventory: a X Cost b Lower of cost or market c Other (attach explanation)
34 Was there any change in determining quantities, costs, or valuations between opening and closing inventory?
If “Yes,” attach explanation . . . . . . . . . . . . . . . . . . . . . . . . . . Yes X No
35 Inventory at beginning of year. If different from last year’s closing inventory, attach explanation . . . 35
36 Purchases less cost of items withdrawn for personal use . . . . . . . . . . . . . . 36
37 Cost of labor. Do not include any amounts paid to yourself . . . . . . . . . . . . . . 37
38 Materials and supplies . . . . . . . . . . . . . . . . . . . . . . . . 38
39 Other costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
40 Add lines 35 through 39 . . . . . . . . . . . . . . . . . . . . . . . . 40
41 Inventory at end of year . . . . . . . . . . . . . . . . . . . . . . . . 41
42 Cost of goods sold. Subtract line 41 from line 40. Enter the result here and on line 4 . . . . . . 42
Part IV Information on Your Vehicle. Complete this part only if you are claiming car or truck expenses on line 9 and
are not required to file Form 4562 for this business. See the instructions for line 13 to find out if you must file
Form 4562.
43 When did you place your vehicle in service for business purposes? (month/day/year) / /
44 Of the total number of miles you drove your vehicle during 2022, enter the number of miles you used your vehicle for:
a Business b Commuting (see instructions) c Other
45 Was your vehicle available for personal use during off-duty hours? . . . . . . . . . . . . . . . Yes No
46 Do you (or your spouse) have another vehicle available for personal use?. . . . . . . . . . . . . . Yes No
47a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . . . Yes No
b If “Yes,” is the evidence written? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

Part V Other Expenses. List below business expenses not included on lines 8–26 or line 30.
CELL PHONE BILL 1563
FURTHER EDUCATION 1365
48 Total other expenses. Enter here and on line 27a . . . . . . . . . . . . . . . . 48 2928

QNA Schedule C (Form 1040) 2022
SCHEDULE SE
Self-Employment Tax
OMB No. 1545-0074
2022
(Form 1040)
Go to www.irs.gov/ScheduleSE for instructions and the latest information.
Internal Revenue Service Attach to Form 1040, 1040-SR, or 1040-NR. Sequence No. 17
Name of person with self-employment income (as shown on Form 1040, 1040-SR, or 1040-NR) Social security number of person
BLAKE D WEBER with self-employment income 259-77-0727
Part I Self-Employment Tax
Note: If your only income subject to self-employment tax is church employee income, see instructions for how to report your income
and the definition of church employee income.
A If you are a minister, member of a religious order, or Christian Science practitioner and you filed Form 4361, but you had
$400 or more of other net earnings from self-employment, check here and continue with Part I . . . . . . . . .
Skip lines 1a and 1b if you use the farm optional method in Part II. See instructions.
1a Net farm profit or (loss) from Schedule F, line 34, and farm partnerships, Schedule K-1 (Form 1065),
box 14, code A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1a
b If you received social security retirement or disability benefits, enter the amount of Conservation Reserve
Program payments included on Schedule F, line 4b, or listed on Schedule K-1 (Form 1065), box 20, code AH 1b ( )
Skip line 2 if you use the nonfarm optional method in Part II. See instructions.
2 Net profit or (loss) from Schedule C, line 31; and Schedule K-1 (Form 1065), box 14, code A (other than
farming). See instructions for other income to report or if you are a minister or member of a religious order 2 3760
3 Combine lines 1a, 1b, and 2 . . . . . . . . . . . . . . . . . . . . . . . . . 3 3760
4a If line 3 is more than zero, multiply line 3 by 92.35% (0.9235). Otherwise, enter amount from line 3 . 4a 3472
Note: If line 4a is less than $400 due to Conservation Reserve Program payments on line 1b, see instructions.
b If you elect one or both of the optional methods, enter the total of lines 15 and 17 here . . . . . 4b
c Combine lines 4a and 4b. If less than $400, stop; you don’t owe self-employment tax. Exception: If
less than $400 and you had church employee income, enter -0- and continue . . . . . . . . 4c 3472
5a Enter your church employee income from Form W-2. See instructions for
definition of church employee income . . . . . . . . . . . . . 5a
b Multiply line 5a by 92.35% (0.9235). If less than $100, enter -0- . . . . . . . . . . . . . 5b
6 Add lines 4c and 5b . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3472
7 Maximum amount of combined wages and self-employment earnings subject to social security tax or
the 6.2% portion of the 7.65% railroad retirement (tier 1) tax for 2022 . . . . . . . . . . . 7 147,000
8a Total social security wages and tips (total of boxes 3 and 7 on Form(s) W-2)
and railroad retirement (tier 1) compensation. If $147,000 or more, skip lines
8b through 10, and go to line 11 . . . . . . . . . . . . . . . 8a 15976
b Unreported tips subject to social security tax from Form 4137, line 10 . . . 8b
c Wages subject to social security tax from Form 8919, line 10 . . . . . . 8c
d Add lines 8a, 8b, and 8c . . . . . . . . . . . . . . . . . . . . . . . . . . 8d 15976
9 Subtract line 8d from line 7. If zero or less, enter -0- here and on line 10 and go to line 11 . . . . 9 131024
10 Multiply the smaller of line 6 or line 9 by 12.4% (0.124) . . . . . . . . . . . . . . . . 10 431
11 Multiply line 6 by 2.9% (0.029) . . . . . . . . . . . . . . . . . . . . . . . . 11 101
12 Self-employment tax. Add lines 10 and 11. Enter here and on Schedule 2 (Form 1040), line 4 . . 12 532
13 Deduction for one-half of self-employment tax.
Multiply line 12 by 50% (0.50). Enter here and on Schedule 1 (Form 1040),
line 15 . . . . . . . . . . . . . . . . . . . . . . . . 13 266
Part II Optional Methods To Figure Net Earnings (see instructions)
Farm Optional Method. You may use this method only if (a) your gross farm income1 wasn’t more than
$9,060, or (b) your net farm profits2 were less than $6,540.
14 Maximum income for optional methods . . . . . . . . . . . . . . . . . . . . . 14 6,040
15 Enter the smaller of: two-thirds (2/3) of gross farm income1 (not less than zero) or $6,040. Also, include
this amount on line 4b above . . . . . . . . . . . . . . . . . . . . . . . . 15
Nonfarm Optional Method. You may use this method only if (a) your net nonfarm profits3 were less than $6,540
and also less than 72.189% of your gross nonfarm income,4 and (b) you had net earnings from self-employment
of at least $400 in 2 of the prior 3 years. Caution: You may use this method no more than five times.
16 Subtract line 15 from line 14 . . . . . . . . . . . . . . . . . . . . . . . . . 16
17 Enter the smaller of: two-thirds (2/3) of gross nonfarm income4 (not less than zero) or the amount on
line 16. Also, include this amount on line 4b above . . . . . . . . . . . . . . . . . 17
1 3
From Sch. F, line 9; and Sch. K-1 (Form 1065), box 14, code B. From Sch. C, line 31; and Sch. K-1 (Form 1065), box 14, code A.
2 4
From Sch. F, line 34; and Sch. K-1 (Form 1065), box 14, code A—minus the amount From Sch. C, line 7; and Sch. K-1 (Form 1065), box 14, code C.
you would have entered on line 1b had you not used the optional method.
For Paperwork Reduction Act Notice, see your tax return instructions. Schedule SE (Form 1040) 2022
QNA
SCHEDULE H Household Employment Taxes OMB No. 1545-0074
(Form 1040)
(For Social Security, Medicare, Withheld Income, and Federal Unemployment (FUTA) Taxes)
Attach to Form 1040, 1040-SR, 1040-NR, 1040-SS, or 1041. 2022
Attachment
Internal Revenue Service Go to www.irs.gov/ScheduleH for instructions and the latest information. Sequence No. 44
Name of employer Social security number
Employer identification number
88-4307277
Calendar year taxpayers having no household employees in 2022 don’t have to complete this form for 2022.
A Did you pay any one household employee cash wages of $2,400 or more in 2022? (If any household employee was your spouse,
your child under age 21, your parent, or anyone under age 18, see the line A instructions before you answer this question.)
X Yes. Skip lines B and C and go to line 1a.
No. Go to line B.
B Did you withhold federal income tax during 2022 for any household employee?
Yes. Skip line C and go to line 7.
No. Go to line C.
C Did you pay total cash wages of $1,000 or more in any calendar quarter of 2021 or 2022 to all household employees?
(Don’t count cash wages paid in 2021 or 2022 to your spouse, your child under age 21, or your parent.)
No. Stop. Don’t file this schedule.
Yes. Skip lines 1a–9 and go to line 10.
Part I Social Security, Medicare, and Federal Income Taxes
1a Total cash wages subject to social security tax . . . . . . . . . . 1a 4438
b Qualified sick and family leave wages paid in 2022 for leave taken after March
31, 2020, and before April 1, 2021, included on line 1a . . . . . . . . 1b 4438
2a Social security tax. Multiply line 1a by 12.4% (0.124) . . . . . . . . . . . . . . . . 2a 550
b Employer share of social security tax on qualified sick and family leave wages paid in 2022 for leave
taken after March 31, 2020, and before April 1, 2021. Multiply line 1b by 6.2% (0.062) . . . . . 2b 275
c Total social security tax. Subtract line 2b from line 2a . . . . . . . . . . . . . . . . 2c 275
3 Total cash wages subject to Medicare tax . . . . . . . . . . . . 3 4438
4 Medicare tax. Multiply line 3 by 2.9% (0.029) . . . . . . . . . . . . . . . . . . . 4 129
5 Total cash wages subject to Additional Medicare Tax withholding . . . . 5
6 Additional Medicare Tax withholding. Multiply line 5 by 0.9% (0.009) . . . . . . . . . . . 6
7 Federal income tax withheld, if any . . . . . . . . . . . . . . . . . . . . . . 7
8a Total social security, Medicare, and federal income taxes. Add lines 2c, 4, 6, and 7. . . . . . . 8a 404
b Nonrefundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021 8b
c Nonrefundable portion of credit for qualified sick and family leave wages for leave taken after March
31, 2021, and before October 1, 2021 . . . . . . . . . . . . . . . . . . . . . 8c 65
d Total social security, Medicare, and federal income taxes after nonrefundable credits. Add lines 8b
and 8c and then subtract that total from line 8a . . . . . . . . . . . . . . . . . . 8d 339
e Refundable portion of credit for qualified sick and family leave wages for leave taken before April 1, 2021 8e 9004
f Refundable portion of credit for qualified sick and family leave wages for leave taken after March 31,
2021, and before October 1, 2021 . . . . . . . . . . . . . . . . . . . . . . . 8f 9489
g Qualified sick leave wages for leave taken before April 1, 2021 . . . . . . . . . . . . . 8g 4438
h Qualified health plan expenses allocable to qualified sick leave wages reported on line 8g . . . . 8h
i Qualified family leave wages for leave taken before April 1, 2021 . . . . . . . . . . . . 8i 4438
j Qualified health plan expenses allocable to qualified family leave wages reported on line 8i . . . . 8j
k Qualified sick leave wages for leave taken after March 31, 2021, and before October 1, 2021 . . . 8k 4438
l Qualified health plan expenses allocable to qualified sick leave wages reported on line 8k . . . . 8l
m Qualified family leave wages for leave taken after March 31, 2021, and before October 1, 2021 . . 8m 4438
n Qualified health plan expenses allocable to qualified family leave wages reported on line 8m . . . 8n
9 Did you pay total cash wages of $1,000 or more in any calendar quarter of 2021 or 2022 to all household employees?
(Don’t count cash wages paid in 2021 or 2022 to your spouse, your child under age 21, or your parent.)
X No. Stop. Include the amount from line 8d above on Schedule 2 (Form 1040), line 9. Include the amounts, if any, from line 8e
on Schedule 3 (Form 1040), line 13b, and line 8f on Schedule 3 (Form 1040), line 13h. If you’re not required to file Form
1040, see the line 9 instructions.
Yes. Go to line 10.
For Privacy Act and Paperwork Reduction Act Notice, see the instructions. Schedule H (Form 1040) 2022
QNA
Form 8995 Qualified Business Income Deduction OMB No. 1545-2294
Simplified Computation
Attach to your tax return.
2022
Internal Revenue Service Go to www.irs.gov/Form8995 for instructions and the latest information. Sequence No. 55
Name(s) shown on return Your taxpayer identification number

Note. You can claim the qualified business income deduction only if you have qualified business income from a qualified trade or
business, real estate investment trust dividends, publicly traded partnership income, or a domestic production activities deduction
passed through from an agricultural or horticultural cooperative. See instructions.
Use this form if your taxable income, before your qualified business income deduction, is at or below $170,050 ($340,100 if married
filing jointly), and you aren’t a patron of an agricultural or horticultural cooperative.
1 (a) Trade, business, or aggregation name (b) Taxpayer (c) Qualified business
identification number income or (loss)
i BARBER SHOPS 88-4307277 3494
ii
iii
iv
2 Total qualified business income or (loss). Combine lines 1i through 1v,

column (c) . . . . . . . . . . . . . . . . . . . . . . 2 3494
3 Qualified business net (loss) carryforward from the prior year . . . . . . . 3 ( )
4 Total qualified business income. Combine lines 2 and 3. If zero or less, enter -0- 4 3494
5 Qualified business income component. Multiply line 4 by 20% (0.20) . . . . . . . . . . . 5 699
6 Qualified REIT dividends and publicly traded partnership (PTP) income or (loss)
(see instructions) . . . . . . . . . . . . . . . . . . . . 6
7 Qualified REIT dividends and qualified PTP (loss) carryforward from the prior
year . . . . . . . . . . . . . . . . . . . . . . . . . 7 ( )
8 Total qualified REIT dividends and PTP income. Combine lines 6 and 7. If zero
or less, enter -0- . . . . . . . . . . . . . . . . . . . . 8
9 REIT and PTP component. Multiply line 8 by 20% (0.20) . . . . . . . . . . . . . . . 9
10 Qualified business income deduction before the income limitation. Add lines 5 and 9 . . . . . . 10 699
11 Taxable income before qualified business income deduction (see instructions) 11 6520
12 Net capital gain (see instructions) . . . . . . . . . . . . . . . 12
13 Subtract line 12 from line 11. If zero or less, enter -0- . . . . . . . . 13 6520
14 Income limitation. Multiply line 13 by 20% (0.20) . . . . . . . . . . . . . . . . . . 14 1304
15 Qualified business income deduction. Enter the smaller of line 10 or line 14. Also enter this amount on
the applicable line of your return (see instructions) . . . . . . . . . . . . . . . . . 15 699
16 Total qualified business (loss) carryforward. Combine lines 2 and 3. If greater than zero, enter -0- . . 16 ( )
17 Total qualified REIT dividends and PTP (loss) carryforward. Combine lines 6 and 7. If greater than
zero, enter -0- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 ( )
For Privacy Act and Paperwork Reduction Act Notice, see instructions. Form 8995 (2022)
QNA
*** FILE COPY ONLY -- DO NOT MAIL ***
____________________________________
**** SUPPORTING NOTES FOR SCHEDULE C
259-77-0727
BLAKE D WEBER
----------------------------------------
Schedule of Materials & Supplies:
Description
___________ Amount
______
SUPPLIES 1,659
BARBER CHAIR 1,253
UNIFORMS 455
LAPTOP 547
PRINTER PENS PAPER 1,236
___________ ______
Total Materials & Supplies: 5,150
----------------------------------------
Schedule of Advertising:
Description
___________ Amount
______
WEB DESIGN 5,643
BUSINESS CARDS 400 382
POP UP SHOPS 430
FB / INSTAGRAM ADS 1,340
___________ ______
Total Advertising: 7,795
----------------------------------------
Schedule of Insurance (other than health):
Description
___________ Amount
______
CAR INSURANCE ( 315 PER MONTH ) 3,780
___________ ______
Total Insurance (other than health): 3,780
----------------------------------------
Schedule of Legal Services:
Description
___________ Amount
______
BANK FEES 400
___________ ______
Total Legal Services: 400
----------------------------------------
Schedule of Repairs and Maintenance:
Description
___________ Amount
______
CAR REPAIRS 1,369
OIL CHANGES 80 PER VISIT (8) 640
___________ ______
Total Repairs and Maintenance: 2,009
*** FILE COPY ONLY -- DO NOT MAIL ***
____________________________________
**** SUPPORTING NOTES FOR SCHEDULE C
259-77-0727
BLAKE D WEBER
----------------------------------------
Schedule of Utilities:
Description
___________ Amount
______
UTILITIES 2,243
INTERNET AND CABLE 1,235
___________ ______
Total Utilities: 3,478
CUSTOMER SERVICE: 800-901-6663
SANTA BARBARA TAX PRODUCTS GROUP, LLC

CIVISTA BANK
REFUND TRANSFER APPLICATION AND AGREEMENT
IMPORTANT DISCLOSURES:
PLEASE READ
If you are owed federal or state tax refunds, you have a right to choose how you will receive these refunds. There
are several options available to you. Some options cost money and some options are free. Please read about these
options below and on the next page.
You can file your tax return electronically or by paper and obtain your federal tax refund(s) directly from the Internal
Revenue Service (“IRS”) for free. Additionally, you can file your state tax return(s) electronically or by paper and
obtain your state tax refund(s) directly from the applicable state taxing authority for free. If you file your federal tax
return electronically, you can receive refund checks directly from the IRS through the U.S. Postal Service in 21 days
from the time you file your federal tax return or the IRS can deposit your refund(s) directly into your bank account in
less than 21 days from the time you file your federal tax return unless there are delays by the IRS. If you file a federal
paper return through the U.S. Postal Service you can receive refund checks directly from the IRS through the U.S.
Postal Service in 6 to 8 weeks from the time the IRS receives your federal return or the IRS can deposit your refund(s)
directly into your bank account in 6 to 8 weeks from the time the IRS receives your federal return. However, if your
federal return contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your refund(s) no
earlier than February 15, 2023. Please consult your applicable state taxing authority’s website for details on when you
can expect to receive your state tax refund(s). If your federal or state tax returns are electronically filed by a
professional, you may have to pay certain fees related to electronic filing such as transmitter fees and electronic filing
fees in addition to the fee charged by your tax preparer for preparing your taxes. Throughout the remainder of the
document, the words “tax return(s)”, “income tax return(s)”, “tax refund(s)” and “refund(s)” refer to both federal and
state, unless otherwise specifically denoted.
You can file your tax return(s) electronically, select a Refund Transfer (“RT”) for an additional fee (the “RT Processing
Fee”), and have your income tax refund(s) processed through a processor using banking services of a financial
institution. An RT allows your refund(s) to be deposited into a bank account intended as a temporary deposit account
(“Deposit Account”) at Civista Bank (“Bank”) and deducts your tax preparation and other fees you authorize from your
refund(s). The balance is delivered to you via the disbursement method you select. If you file your tax return(s)
electronically and select an RT, the IRS or applicable state taxing authority will deposit your refund(s) with Bank. Upon
Bank’s receipt of your refund(s), Santa Barbara Tax Products Group, LLC, a division of Green Dot Corporation, a
Delaware corporation (“Servicer”), a processor, will deduct and pay from your refund(s) the RT Processing Fee, any
fees charged by your tax preparer for the preparation and filing of your tax return(s) and any other amounts
authorized by you, and disburse the balance of your refund proceeds to you. Unless there are delays by the IRS, federal
tax refunds are received in less than 21 days from the time you file your federal tax return electronically. However, if
your federal tax return contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your federal
tax refund no earlier than February 15, 2023. Please consult your applicable state taxing authority’s website for details
on when you can expect to receive your state tax refund(s). An RT Processing Fee of $39.95 is charged to process your
federal or state tax refunds. The RT Processing Fee will be increased by $14.95 if Servicer processes federal and state
refunds for you (and an additional $14.95 fee will be incurred for each state if multiple state returns are processed).
In connection with an RT, in addition to the RT Processing Fee, you may have to pay certain other charges and fees,
including a transmission fee, a technology fee and an electronic filing fee that may be payable to the transmitter or
your tax preparer. Additional fees may apply depending on the disbursement method you select.
An RT is not necessary to obtain your refund(s). If you have an existing bank account you do not need an RT, which
requires the payment of a fee, in order to receive a direct deposit from the IRS or applicable state taxing authority.
You may consult the IRS website (IRS.gov) or website of the applicable state taxing authority for information about
tax refund processing.
2023 RT Application and Agreement_CAF 2023-1B, January 2023

If you select an RT, no prior debt you may owe to Bank will be deducted from your refund(s). You can change your
income tax withholdings which might result in you receiving additional funds throughout the year rather than
waiting to receive these funds potentially in the form of an income tax refund next year. Please consult your
employer or tax advisor for additional details.
This Agreement requires all disputes to be resolved by way of binding arbitration. The terms of the arbitration
provision appear in Section 13.
Information regarding low-cost deposit accounts may be available at www.mymoney.gov.
Questions? Call 800-901-6663
The chart below shows the options for filing your federal and state tax returns (e-file or paper returns), when
payment for services is due, the RT product, refund disbursement options, estimated timing for obtaining your tax
refund proceeds, and costs associated with the various options. Please read and review carefully all contract
documents for specific information about your options.
WHAT TYPE OF WHEN IS PAYMENT WHAT ARE YOUR WHAT IS THE WHAT COSTS DO
FEDERAL AND FOR TAX DISBURSEMENT ESTIMATED TIME YOU INCUR IN
STATE TAX RETURN PREPARATION OPTIONS? TO RECEIVE ADDITION TO TAX
FILING METHOD? SERVICES DUE? REFUNDS? PREPARATION
FEES?
PAPER Payment is due at IRS or applicable Approximately No additional cost.
RETURN the time your state taxing 6 to 8 weeks3
federal or state authority issues
No Refund Transfer paper returns are direct deposit to Check website for
prepared and your personal bank applicable state
delivered to you for account. taxing authority
filing. Check mailed by IRS Approximately
or applicable state 6 to 8 weeks3
taxing authority to
address on tax Check website for
return. applicable state
taxing authority
ELECTRONIC Payment is due at IRS or applicable Usually within No additional cost.
FILING the time of e-filing state taxing 21 days3
(E-FILE) federal or state authority issues
returns. direct deposit to Check website for
No Refund Transfer your personal bank applicable state
account. taxing authority
Check mailed by IRS Approximately
or applicable state 21 to 28 days3
taxing authority to
address on tax Check website for
return. applicable state
taxing authority
ELECTRONIC Payment is due (a) Direct deposit Usually within $39.954
FILING when your federal to your bank 21 days3
(E-FILE) or state tax refund account,
proceeds have Check website for
Refund Transfer been disbursed to (b) Load to your applicable state
you as authorized GO2bank Visa® taxing authority
from the Deposit Debit Card1, or

Account or
returned to the IRS (c) Check2
or applicable state
taxing authority.
1
You may incur additional charges from the issuer of the debit card if you select to have your tax refund(s) loaded
on a debit card. Bank is not affiliated with the issuer of the debit card.
2
An additional $12.00 check administration fee may apply. See Section 5 of the Agreement for more details.
3
However, if your tax return contains Earned Income Tax Credit or Additional Child Tax Credit, the IRS will issue your
refund(s) no earlier than February 15, 2023.
4
The RT Processing Fee will be increased by $14.95 if Servicer processes federal and state refunds for you (and an
additional $14.95 fee will be incurred for each state if multiple state returns are processed). In addition, you may
have to pay certain other charges and fees beyond this amount, including a transmission fee, a technology fee and
an electronic filing fee that may be payable to the transmitter or the tax return preparer. These fees may include a
processing fee payable to Servicer, in addition to the RT Processing Fee, if fees are due to your tax preparer for
preparing your tax documents. This fee will be calculated according to the following schedule depending on the
amount of fee due to your tax preparer for preparing your tax documents:
Tax Preparer Fee Range Servicer Fee
$0.01-50.00 $5
$50.01-100.00 $7
$100.01-150.00 $10
The IRS or applicable state taxing authority does not guarantee that you will be paid the full amount of an anticipated
tax refund and does not guarantee that an anticipated tax refund will be deposited into your account or mailed to
you on a specific date.
Questions? Call 800-901-6663

SANTA BARBARA TAX PRODUCTS GROUP, LLC

CIVISTA BANK
REFUND TRANSFER APPLICATION AND AGREEMENT
APPLICANT INFORMATION (Complete for both taxpayers if filing a joint return)
Taxpayer’s Name _______________________________

BLAKE D WEBER Taxpayer’s Name ____________________________
Social Security No. _______________________________

259-77-0727 Social Security No. __________________________
Taxpayer’s Cell Phone No. _________________________

404-545-6279 Email Address _______________________________
Jaxweber8892@gmail.com
It’s extremely important to ensure your correct email address is
inserted to ensure you receive status notifications.
1.a.___
X Texting Opt-In for Santa Barbara Tax Products Group, LLC and Bank: If checked, you hereby verify that the cell phone number provided
above is your mobile number and you consent to receive optional servicing, promotional and marketing text messages at this number from or
on behalf of Santa Barbara Tax Products Group, LLC, a division of Green Dot Corporation, a Delaware corporation (“Servicer”), and Civista Bank
(“Bank”) regarding the status or approval of products and services you requested pursuant to this Refund Transfer Application and Agreement
and additional products or services that may be offered by Servicer or Bank. Your standard message and data rates may apply. You understand
and agree that Servicer and Bank can deliver SMS messages using an automatic telephone dialing system and that you do not need to sign
up for text notifications in order to purchase or obtain any products or services from Servicer or Bank. You may text “STOP” in response to
the message to cancel at any time.
1.b.___
X Texting Opt-In for First Century Bank, N.A.: If checked, you hereby verify that the cell phone number provided above is your mobile
number and you consent to receive optional servicing text messages at this number from or on behalf of First Century Bank, N.A. (“FCB”)
regarding the status of your Fast Cash Advance Refund Advance Loan Agreement submitted to FCB. Your standard message and data rates
may apply. You understand and agree that FCB can deliver SMS messages using an automatic telephone dialing system and that you do not
need to sign up for text notifications in order to purchase or obtain any products or services from Servicer, Bank or FCB. You may text 89817
the words “HELP” for help or “STOP” to cancel at any time, and message frequency varies. The Fast Cash Advance Refund Advance Loan
Agreement and Privacy Policy for FCB that apply to the loan are provided with this documentation for reference and can be found at
https://www.myfirstcenturybank.com/policies/texting/ and https://myfirstcenturybank.com/wp-content/uploads/2021/09/First-Century-
Bank-Privacy-Policy-2020-07_NEW.pdf.
1.c.___ Emailing Opt-In: If checked, you hereby verify that the email address provided above is your email address and you consent to receiving
optional promotional and marketing emails at this address from or on behalf of Santa Barbara Tax Products Group, LLC, a division of Green
Dot Corporation, a Delaware corporation (“Servicer”), and Bank regarding additional products or services that may be offered by Servicer or
Bank. You understand and agree that you do not need to sign up for promotional and marketing emails in order to purchase or obtain any
products or services from Servicer or Bank. You may withdraw your consent to receiving promotional and marketing emails at any time in
the future by using the link provided at the bottom of each promotional or marketing email.
2. REFUND TRANSFER AND TAX REFUND ACCOUNT: As used in this Refund Transfer Application and Agreement (“Agreement”), the
terms “you” and “your” refer to the person signing below as the “Taxpayer” (or, if a joint return is being filed, both “Taxpayers”). The term
“Bank” refers to Civista Bank located in Sandusky, Ohio. The term “Servicer” refers to Santa Barbara Tax Products Group, LLC, a division of
Green Dot Corporation, a Delaware corporation, which acts as a processor for your income tax refund(s). The terms “we”, “our”, and “us” refer
to Bank and/or Servicer. You are having your 2022 federal (and state(s), if applicable) income tax return(s) prepared and filed by your Tax
Preparer/Electronic Filer (“Tax Preparer”) and hereby authorize Bank to receive your income tax refund(s) on your behalf and authorize Servicer
to make disbursements from your refund(s) as authorized by this Agreement. You authorize Bank to establish a temporary deposit account
(the “Account”) in your name for the purpose of receiving a direct deposit of your tax refund(s) from the Internal Revenue Service (“IRS”) or
applicable state taxing authorities. You agree to pay a tax refund transfer processing fee (the “RT Processing Fee”) and you may have to pay
certain other charges and fees, including a transmission fee, a technology fee and an electronic filing fee payable to the tax software company
that assists in transmitting your return to the IRS or applicable state taxing authority (the “Transmitter”) and/or your Tax Preparer. These fees
may include a processing fee payable to Servicer, in addition to the RT Processing Fee, in the amount set forth in the footnote to the above
chart if fees are due to your Tax Preparer for preparing your tax documents. If and when Bank receives your income tax refund(s), you authorize
Servicer to deduct from your Account an RT Processing Fee of $39.95, an additional $14.95 RT Processing Fee per tax refund if more than one
refund is processed (i.e., federal and state or multiple states), your tax preparation fees, any other fees assessed by your Tax Preparer or by
the Servicer or Transmitter, and any other amounts, fees and charges authorized by this Agreement, and to disburse any remaining balance in
the Account to you using the disbursement method indicated below. Additional fees may apply, depending on the disbursement method you
select. See the Refund Transfer Fee Disclosure for an itemization and explanation of these charges. In the event the fees or other amounts due
for products or services set forth in this Agreement are not fully paid from your federal and/or state refunds for any reason, including
repayment of and interest associated with refund advance products (“Outstanding Amounts”), any Outstanding Amounts may be deducted
from refunds that you may receive up to 24 months after the date of this Agreement and process through the Servicer. In the event the tax
preparation, document preparation and electronic filing fees set forth in this Agreement (“Tax Prep Fees”) are not fully paid from your federal
and/or state refunds for any reason or if we, in our sole discretion, consider your refund proceeds delayed based on applicable tax deadlines
set by the IRS, you authorize Servicer to automatically debit such Tax Prep Fees from your account set forth in Section 5 (the “Auto-Collect
Program”). Note that the Auto-Collect Program only applies for those taxpayers not subject to an “opt-out” per Section 5. According to the
IRS, unless there are delays by the IRS, you can generally expect the IRS to issue your refund to be direct deposited with Bank in less than 21
days from the time the IRS accepts your electronic tax return. However, if your return contains Earned Income Tax Credit or Additional Child
Tax Credit, the IRS will issue your refund no earlier than February 15, 2023. Please consult your applicable state taxing authority’s website for
details on when you can expect to receive your state tax refund(s).
X
3.___ FEDERAL REFUND TRANSFER: You hereby authorize Bank to receive and Servicer to process your federal tax refund(s) as described in
Section 2 using the disbursement method selected in Section 5.
4.___ STATE REFUND TRANSFER: You hereby authorize Bank to receive and Servicer to process your state tax refund(s) as described in Section
2 using the disbursement method selected in Section 5.
5. DISBURSEMENT METHODS (Select One): Your tax refund proceeds and, if applicable, tax refund advance products from a third
party service provider, less fees and interest authorized under this Agreement, shall be disbursed to you using the disbursement method
you select below.
___ Cashier’s Check: You request Servicer to disburse your tax refund proceeds by a cashier’s check printed by your Tax Preparer. You may be
charged a $12.00 check administration fee for this disbursement option, which will be deducted from your tax refund proceeds. This fee applies
to disbursements of both federal and state tax refunds and applies to each cashier’s check printed. Servicer, Transmitter and Tax Preparer will
each receive a portion of this fee. Inquire with your Tax Preparer to determine applicability of this fee.
___
X Direct Deposit: You request Servicer to deposit your tax refund proceeds directly into your personal bank account or your existing prepaid
debit card account. If you select this option, please enter your account information below. If you or your representative enters your account
information incorrectly and your funds are returned to Bank, the funds will be disbursed to you by a cashier’s check printed by your Tax
Preparer. Tax refund proceeds that cannot be direct deposited because of financial institution refusal, erroneous account or routing transit
numbers, closed accounts, bank mergers or any other reason will be issued as a paper check to the physical address of record resulting in
refund delays of up to ten weeks.
By selecting this direct deposit method, you authorize Servicer to electronically debit your personal bank account noted below for Tax Prep
Fees in the event i) your Tax Prep Fees are not fully paid from your federal and/or state refunds for any reason or if we consider, in our sole
discretion, your refund proceeds delayed based on applicable tax deadlines set by the IRS, and ii) your Tax Preparer has not opted out of the
Auto-Collect Program or has not opted you, specifically, out of the Auto-Collect Program. You may also opt out of the Auto-Collect Program
by notifying Servicer at least three business days prior to the date that your account is scheduled to be debited per the notices sent to you
by writing to us at: Santa Barbara Tax Products Group, LLC, PO Box 817, West Chester, OH 45071. We will e-mail or mail a notice to you stating
the amount due and the date we will electronically debit your account at least 10 days before so you may have a chance to pay the outstanding
balance. We may attempt to electronically debit your account for a second time if we receive a notice of non-sufficient funds. Note that any
Outstanding Amounts not collected pursuant to the Auto-Collect Program may still be recovered pursuant to Section 2.
125109019
Routing No. (RTN): _________________________ 875103673534
Deposit Acct. No. (DAN): _________________________________________
___ GO2bank Visa® Debit Card (“Card”): You request Servicer to deposit your tax refund proceeds to the Card you have obtained or are
obtaining. The Card is issued by Green Dot Bank, Member FDIC, pursuant to a license from Visa. You represent that you have received and
reviewed the Deposit Account Agreement containing the terms and conditions applicable to the Card, including the fees and charges that
apply to the Card.
Neither Bank nor Servicer is responsible for the misapplication of funds that results from error, negligence or malfeasance on your part or on
the part of the Tax Preparer. In cases where Bank has received your tax refund(s) but is unable to deliver the tax refund proceeds directly to
you for any reason, the funds will be returned to the IRS or the appropriate state taxing authority.
6. CONSENT/AUTHORIZATION: If and when Bank receives your tax refund(s), Servicer will process them in accordance with Section 2
using the disbursement method selected by you in Section 5. The RT Processing Fee and any other fees and charges authorized by this
Agreement will be deducted from the Account before the balance of your tax refund proceeds is disbursed to you. Your refund(s) may be held
or returned to the IRS if fraud or identity theft is suspected. If your refund(s) cannot be delivered for any reason, you will be charged an additional
fee of $30.00 (the “Return Item Fee”) for the additional processing required and additional attempts to deliver the refund(s). You may also be
charged an additional fee of $30.00 (the “Account Research and Processing Fee”) for the additional handling required to return your funds to
the IRS or applicable state taxing authority after failed attempts to deliver the refund(s). The Return Item Fee and the Account Research and
Processing Fee will be deducted from the proceeds of the Account and retained by Servicer. Please refer to the Truth in Savings Disclosure section
of this Agreement for more information on fees.

Unless you are subject to an “opt-out” of the Auto-Collect Program in accordance with Section 5, you authorize Servicer to electronically debit
your account as set forth in Section 5. You understand that this authorization will remain in full force and effect until there is a valid “opt-out”.
7. SHARING INFORMATION: You authorize the Tax Preparer, Transmitter and the IRS or applicable state taxing authority to disclose
your 2022 tax return(s) and refund information to Bank and Servicer, and for Bank and Servicer to exchange such information, for the purpose
of providing the services contemplated under this Agreement and pursuant to the Privacy Policy provided at the end of this Agreement. You
acknowledge that Bank and Servicer may share information about you with the Tax Preparer, the Transmitter and other third-party product
providers to the extent necessary to process your tax product request. This sharing is not subject to your further consent or right to opt out.
For more information regarding Bank’s privacy policies please see the Privacy Policy at the end of this Agreement.
8. CURRENT YEAR LOAN: If you obtain one or more tax refund advance products from a third party provider, you authorize (a) Servicer
to deduct the amount of all such refund advance proceeds and any applicable interest for the tax refund advance product from your federal
or state refund amounts as explained in Section 2, and pay or transfer such amounts to such refund advance provider on your behalf, and (b)
if the IRS initially rejects your e-filed tax return after you have received a tax refund advance and you re-submit your tax return to the IRS, this
Agreement will remain in full force and effect and cannot be rescinded in connection with your subsequent submission of your tax return to
the IRS. Neither Bank nor Servicer is a provider of the third party refund advance product and neither is affiliated with the associated refund
advance provider.
9. SECURITY INTEREST AND ASSIGNMENT: You hereby assign to Servicer your 2022 federal and state, if applicable, income tax refund(s)
and your Account, and all current and future funds deposited therein, to the extent necessary to facilitate collection by Servicer of any amounts
authorized by this Agreement. You also grant Servicer a security interest in the same. You agree that Servicer may assign, sell or transfer its
ownership of all or part of its rights arising under this Agreement to a third party or affiliate of Servicer. You may not revoke this security
interest or any assignment.
10. MISCELLANEOUS: (a) The provisions in this Agreement survive the disbursement of any tax refund proceeds to you; (b) the
enforcement and interpretation of this Agreement and the transactions contemplated herein shall be governed by the laws of the United
States and, to the extent state law applies, the substantive laws of Ohio; and (c) to the extent permitted by applicable law, you agree to pay
any costs of collection, including reasonable attorneys’ fees, if any amount due under this Agreement is not paid when due.
11. ACKNOWLEDGEMENT REGARDING FEES AND SERVICES: You agree that neither your Tax Preparer, the Transmitter, Bank nor Servicer
is acting as your agent or is under any fiduciary duty to you regarding this Agreement. Among other things, you agree and consent to the
receipt by your Tax Preparer, the Transmitter and Servicer of fees as set forth in this Agreement. You acknowledge that the services provided
by your Tax Preparer and/or Transmitter pursuant to this Agreement are not complete until your tax refund proceeds have been disbursed to
you by Servicer or such time that it appears that no tax refund(s) will be received.
12. COMPENSATION: Servicer will pay compensation to the Transmitter and may pay compensation to the Tax Preparer in consideration
of rights granted by the Transmitter and Tax Preparer and the performance of services by the Transmitter and Tax Preparer. Additionally,
Servicer will pay compensation to Bank for its banking services and will retain the RT Processing Fee for Servicer’s processing services.
13. ARBITRATION PROVISION: You acknowledge that the services set forth in this Agreement are being made available and priced by
the Servicer on the basis of your acceptance of the following arbitration provision (“Arbitration Provision”). By entering into this Agreement,
you acknowledge that you are giving up the right to litigate Claims (as defined below) if either party elects arbitration of the Claims pursuant
to this clause, except as otherwise expressly provided herein, and you hereby knowingly and voluntarily waive the right to trial of all Claims
subject to this Agreement. You further acknowledge that you have read this Arbitration Provision carefully, agree to its terms, and are
entering into this Agreement voluntarily and not in reliance on any promises or representations whatsoever except those contained in this
Agreement.
ARBITRATION NOTICE
THIS AGREEMENT CONTAINS AN ARBITRATION PROVISION. PLEASE READ THIS PROVISION CAREFULLY, AS IT AFFECTS YOUR LEGAL RIGHTS.
13.1. Arbitration of Claims: Except as expressly provided herein, any claim, dispute or controversy (whether based upon contract; tort,
intentional or otherwise; constitution; statute; common law; or equity and whether pre-existing, present or future), including initial claims,
counter-claims, cross-claims and third-party claims, arising from or relating directly or indirectly to this Agreement, including the validity,
enforceability, interpretation, scope, or application of the Agreement and this Arbitration Provision (except for the prohibition on class or
other non-individual claims, which shall be for a court to decide) (“Claim”) shall be decided, upon the election of you or us (or our agents,
employees, successors, representatives, affiliated companies, or assigns), by binding arbitration. Arbitration replaces the right to litigate a
claim in court or to have a jury trial. Regardless of who demands arbitration, you shall have the right to select either of the following arbitration
organizations to administer the arbitration: the American Arbitration Association ((1-800-778-7879; http://www.adr.org) or Judicial Arbitration
and Mediation Services (1-800-352-5267; http://www.jamsadr.com). You may obtain copies of the current rules, forms, and instructions for
initiating an arbitration with either organization by contacting them using the above information.

13.2. Other Claims Subject to Arbitration: In addition to Claims brought by you, Claims made by anyone connected with you or anyone making
a Claim through you (including a taxpayer filing jointly, employee, agent, representative, affiliated company, predecessor or successor, heir,
assignee, or trustee in bankruptcy) against us shall be subject to arbitration as described herein.
13.3. Exceptions: We agree not to invoke our right to arbitrate any individual Claim you bring in small claims court or an equivalent court so
long as the Claim is pending only in that court. This Arbitration Provision also does not limit or constrain our right to interplead funds in the
event of claims to the Account by several parties.
13.4. Individual Claims Only: Claims may be submitted to arbitration on an individual basis only. Claims subject to this Arbitration Provision
may not be joined or consolidated in arbitration with any Claim of any other person or be arbitrated on a class basis, in a representative
capacity on behalf of the general public or on behalf of any other person, unless otherwise agreed to by the parties in writing. However,
taxpayers filing jointly and party to this Agreement are considered as one person; Servicer and its officers, directors, employees, agents, and
affiliates are considered as one person; and Bank and its officers, directors, employees, agents, and affiliates are considered as one person.
13.5. Arbitration Fees: If you initiate arbitration, we will advance any arbitration fees, including any required deposit. If we initiate or elect
arbitration, we will pay the entire amount of the arbitration fees, including any required deposit. We will also be responsible for payment
and/or reimbursement of any arbitration fees to the extent that such fees exceed the amount of the filing fees you would have incurred if your
Claim had been brought in the state or federal court nearest your residence with jurisdiction over the Claims.
13.6. Procedure: A single arbitrator will resolve the Claims. The arbitrator will be a lawyer with at least ten years’ experience or who is a former
or retired judge. The arbitration shall follow the rules and procedures of the arbitration administrator in effect on the date the arbitration is
filed, except when there is a conflict or inconsistency between the rules and procedures of the arbitration administrator and this Arbitration
Provision, in which case this Arbitration Provision shall govern. Any in-person arbitration hearing for a Claim shall take place within the federal
judicial district in which you live or at such other reasonably convenient location as agreed by the parties. The arbitrator shall apply applicable
substantive law consistent with the Federal Arbitration Act, 9 U.S.C. § 1 et seq. (the “FAA”) and shall honor all claims of privilege and
confidentiality recognized at law. All statutes of limitations that would otherwise be applicable shall apply to any arbitration proceeding. The
arbitrator shall be empowered to grant whatever relief would be available in court under law or in equity. Any appropriate court may enter
judgment upon the arbitrator’s award. This Arbitration Provision is made pursuant to a transaction involving interstate commerce, and shall
be governed by the FAA.
14. FEDERAL ELECTRONIC FUND TRANSFER ACT DISCLOSURES: In case of errors or questions about electronic transfers to or from the
Account, write to Santa Barbara Tax Products, Group, LLC, PO Box 817, West Chester, OH 45071 or telephone (800) 901-6663 and provide your
name, a description or explanation of the error, when the error took place and the dollar amount of the suspected error. We will determine
whether an error occurred within 10 business days after we hear from you and will correct any error promptly. If we need more time, however,
we may take up to 45 business days to investigate your complaint or question. If we decide to do this, Servicer will credit your Account within
10 business days for the amount you think is in error, although in most circumstances you won’t have use of the money until we complete our
investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10 business days, Servicer may not
credit your Account. For errors involving transfers of funds to or from the Account within 30 business days after the first deposit to the Account
was made, (i) we may take up to 90 days to investigate your complaint or question, and (ii) Servicer may take up to 20 business days to credit
your Account for the amount you think is in error. We will tell you the results within three business days after completing our investigation. If
we decide that there was no error, we will send you a written explanation. You may ask for copies of the documents that we used in our
investigation.
15. BUSINESS DAYS: Our business days are Monday through Friday, excluding federal holidays. Saturday, Sunday, and federal holidays
are not considered business days, even if we are open.
16. CONFIDENTIALITY: We will disclose information to third parties about your Account or the transfers you make:
• To complete transfers as necessary;
• To verify the existence and condition of your Account upon the request of a third party, such as a credit bureau or merchant;
• To comply with government agency or court orders;
• If you give us your written permission; or
• As explained in the Privacy Policy following this Agreement.
17. OUR LIABILITY: If we do not complete a transfer to your Account on time or in the correct amount according to this Agreement, we
may be liable for your losses or damages. In addition to all other limitations of our liability set forth in this Agreement, we will not be liable to
you if, among other things:
• Circumstances beyond our control (such as fire, flood, water damage, power failure, strike, labor dispute, pandemic, computer
breakdown, telephone line disruption, or a natural disaster) prevent the transfer, despite reasonable precautions that we have taken.
• The funds in your Account are subject to legal process or other claim restricting such transfer.
• You, your representative or a third-party provide us with inaccurate or untimely information.
18. TAXPAYER IDENTITY VALIDATION DISCLOSURE: To help Bank, Servicer and the government identify and fight tax refund fraud, as
well as fight the funding of terrorism and money laundering activities, Bank and Servicer obtain, verify, and record information that identifies
each Taxpayer. What this means for you: In order to carry-out the services hereunder, we will ask for your name, address, date of birth, and

other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents if we need to
perform additional due diligence on your account.
19. TRUTH IN SAVINGS DISCLOSURE: The Account is being opened for the purpose of receiving your (or both taxpayers if this is a jointly
filed return) 2022 federal (and 2022 state, if applicable) income tax refund(s). Servicer will charge the fees set forth in Section 2 above for opening
and maintaining the Account and processing your tax refund(s). No other deposits may be made into the Account. No withdrawals will be allowed
from the Account except to collect the fees set forth in this Section and in Section 2 above. No interest will be paid on Account funds; thus, the
annual percentage yield and interest rate are 0%. The Account will be closed after all authorized deductions have been made and any remaining
balance has been disbursed to you. Servicer will charge a Return Item Fee of $30.00 if the tax refund proceeds cannot be delivered as directed
in Section 5 of this Agreement. An Account Research and Processing fee of $30.00 may be charged if Servicer is required to provide additional
processing to return the funds to the IRS or applicable state taxing authority after failed attempts to deliver the refund(s). These fees will be
deducted from the Account and retained by Servicer.
20. PRIVACY POLICY: Please see the Privacy Policy at the end of this Agreement.
Bank and Servicer agree to all the terms of this Agreement.
SIGNATURES: By signing below, you represent that everything you have stated in this Agreement is true and correct. You
represent that you have read and understand each of the terms and conditions herein and that you agree to each of these
terms and conditions. You acknowledge receiving a completed copy of this Agreement and, among other things, consent to
the collection authorization in Section 9 above, if applicable, the Auto-Collect Program as set forth in Section 5, as applicable,
and the Arbitration Provision in Section 13 above which may substantially limit your rights in the event of a dispute.
____________________________________________ ___________________________________________________
Taxpayer/Applicant Date Taxpayer/Applicant (if filing jointly) Date

Rev 09/2021
Civista Bank Tax Product Privacy Policy
FACTS What does Civista Bank do with your Personal Information?
Why? Financial Companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you how
we collect, share and protect your personal information. Please read this notice carefully to
understand what we do.
What? The types of personal information that we collect and share depend on the product or service
you have with us. This can include:
• Social Security number and account balances

• payment history and transaction history
• overdraft history and account transactions
When you are no longer our customer, we continue to share your information as described in
this notice.
How? All Financial Companies need to share customers’ personal information to run their everyday
business. In the section below we list the reasons financial companies can share their customers’
personal information; the reasons Civista Bank chooses to share and whether you can limit the
sharing.
Reasons we can share your personal information Does Civista Bank share? Can you limit this sharing?
For our everyday business purposes- Yes No
such as to process your transaction, maintain your
account(s), respond to court orders and legal
investigations, or report to credit bureaus.
For our marketing purposes- Yes No
to offer our products and services to you.
For joint marketing with other financial companies. Yes No
For our affiliates’ everyday business purposes- No We don’t share
information about your transactions and experiences.
For our affiliates’ everyday business purposes- No We don’t share
information about your creditworthiness.
For our affiliates to market to you. No We don’t share
For non affiliates to market to you. No We don’t share
Questions? Call Toll Free: 800-901-6663 or go to www.civista.bank

Who we are
Who is providing this notice? Civista Bank
What we do
How does Civista Bank protect my personal To protect your personal information from unauthorized access
information? and use, we use security measures that comply with federal law.
These measures include computer safeguards and secured files
and buildings.
How does Civista Bank collect my personal We collect personal information about you when you apply for a
information? tax related product. This includes information in your
application, such as your name, address, social security number,
income, deductions, refund and the like. We also collect
information about your transactions with us, tax preparers and
similar providers, such as payment histories, balances due, and
tax information. We may also collect information concerning
your credit history from a consumer reporting agency.
Why can’t I limit all sharing? Federal law gives you the right to limit only:
• Sharing for affiliates everyday business purposes-

information about your creditworthiness,
• Affiliates from using your information to market to you,
• Sharing for non affiliates to market to you.
State laws and individual companies may give you additional

rights to limit sharing.
Definitions
Affiliates Companies related by common ownership or control. They can
be financial and nonfinancial companies.
• Civista Bank does not share with our affiliates.
Non affiliates Companies not related by common ownership or control. They

can be financial or nonfinancial companies.
• Civista Bank does not share with non affiliates so they

can market to you.
Joint Marketing A formal joint marketing agreement between non affiliated

financial companies that together market financial products or
services to you.
• Our joint marketing providers include: financial service

providers that offer additional payment products.
Other Important Information

This Notice is adopted in recognition of our obligations under Title V of Gramm-Leach Bliley Act of 1999.
This Notice applies only to individuals who have applied for a tax-related bank product.

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Fast Cash Advance Refund Loan Disclosure

First Century Bank, N.A. (“FIRST CENTURY”) offers a Fast Cash Advance Refund Loan (“Refund Advance
Loan”) for qualified customers starting in January 2, 2023 and through March 17, 2023. FIRST CENTURY’s
Refund Advance Loan is available to qualifying customers based on several factors including but not limited
to your expected tax refund. Refund Advance Loans are made for $500 up to $7,000. A Refund Advance
Loan has an ANNUAL PERCENTAGE RATE (“APR”) of 35.99%. FIRST CENTURY will underwrite you
for all available loan amounts and will notify you of its decision (if your application is approved, it will be for
the highest amount for which you qualify). FIRST CENTURY cannot make a final decision on your loan
application until you provide your tax preparer with the tax forms necessary to prepare your tax return and
your tax return is completed. To be approved for a Refund Advance Loan, you must meet all of our
underwriting criteria. A Refund Advance will be deducted from your federal tax refund proceeds and, if
permitted by state law, your state tax refund proceeds, and will reduce the amount you can expect to receive
from a tax refund. To better understand our Refund Advance Loan and IRS Tax Refunds, including the
expected refund timing table, see below:
Refund Advance Loan of $500 to

Interest accrues daily, and the APR is 35.99%.
$7,000
Customer Service Contact Information (Subject to Change upon Notice to You):

First Century Bank, N.A., Attn: Fast Cash Advance Refund Loans, P.O. Box 23679, Hilton Head Island, SC
29925-3679 (“Customer Service Address”). Customer Service Calls may be made to our Servicer at 855-
459-9226 (“Toll-Free Customer Service Number”).
General Customer Frequently Asked Questions (FAQs) about Refund Advance

Loans
The money you receive from FIRST CENTURY is a loan and is
not your actual tax refund. It is a single advance of funds and
Is the money received from FIRST
not to be used on a long-term basis. The loan must be repaid
CENTURY the customer’s actual tax refund
according to the contract terms. You may consult the IRS
or a loan?
Web site (www.irs.gov) or the applicable tax authority for
information about tax refund processing.
First Century Bank, N.A., P.O. Box 23679, Hilton Head Island,
Who is making and underwriting the loan?
SC 29925-3679.
FIRST CENTURY will begin offering Refund Advance Loans
When can I start applying for a loan? starting on January 2, 2023 and continuing through March 17,
2023.
Your tax return must be prepared by your tax preparer in order to
What information is necessary to apply?
apply for a Refund Advance Loan.
We offer one Refund Advance Loan to qualifying customers, which
What kind of loans are offered? is an interest-bearing loan. The loan is intended for one-time use
only.
What are the minimum and maximum Refund We offer Refund Advance Loan amounts to qualifying customers in
Advance Loan amounts? amounts between $500 and $7,000.
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Our Refund Advance Loan has an ANNUAL PERCENTAGE

RATE (APR) of 35.99%. See your contract documents for your
How much does the Refund Advance Loan specific terms and conditions.
cost?
Customers applying for a Refund Advance Loan amount are

underwritten by FIRST CENTURY for all available loan amounts
How can I apply for a Refund Advance Loan? between $500 and $7,000. If your loan is approved, it will be for
the highest amount for which you qualify.
If you request a Refund Advance Loan amount and FIRST

CENTURY is unable grant the credit, then FIRST CENTURY will
What happens if a loan request is denied?
send you a letter about its decision.
You will sign and submit an application, and FIRST CENTURY will
underwrite you for all available loan amounts ranging from $500 to
$7,000. Because we cannot know the exact loan amount you will
How does the application process work if I
receive, we first will provide you with “estimated” Truth-In-Lending
want a Refund Advance Loan?
disclosures. When we notify you of your loan approval, we will
provide an additional Truth-in-Lending disclosure that indicates
your final loan amount as the “Amount Financed.” Upon approval
and funding, the loan agreement will become effective.
The Refund Advance Loan Agreement you sign is “conditional.”

That is, the Refund Advance Loan will become effective and
What is a “conditional” loan agreement? binding upon the parties only after approval and funding by FIRST
CENTURY.
If state law does not permit repayment of the Refund Advance

Loan from the state tax refund or you do not receive a state refund,
then the Refund Advance Loan will be repaid solely from your
federal tax refund. If approved, the Refund Advance Loan is due
when you receive your tax refund(s). The Refund Advance Loan is
secured by your tax refund(s) if allowed by law. As such, the
Refund Advance Loan amount will be automatically deducted from
the bank account receiving the tax refund proceeds. The tax
refund amounts you receive from the IRS and, if applicable and
When will the loan be due and how will it be allowed by law, from a state taxing authority, will be reduced by the
repaid? amount of the loan. If you will receive multiple tax refunds and the
amount of the first tax refund you receive is insufficient to pay your
obligations in full, then the outstanding balance owing will be paid
upon receipt of the subsequent tax refund, if applicable and
permitted by state law. If the total amount of your tax refund or
refunds is insufficient to pay the full amount of your Refund
Advance Loan, you will not be required to repay the balance
remaining after your tax refund or refunds have been applied to
repay your loan.
Yes. You can always make prepayments and will never incur an
additional charge, fee or penalty. In addition, because the Refund
Advance Loan charges simple interest, each prepayment you
make will be applied first to principal and then to accumulated
Can I prepay a Refund Advance Loan?
interest, potentially reducing the amount of finance charge you will
pay. You can always call the customer service line at (855) 459-
9226 to request a payoff amount.
Are there any fees and charges, other than No. Other than the simple interest charged on the Refund
interest disclosed as a “finance charges,” Advance Loan amounts, FIRST CENTURY does not charge any
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associated with the Refund Advance Loan? other fees for the loan. You may pay fees for other products that
you choose, including fees to your tax preparer for your tax
preparation and filing, fees for a Refund Transfer (if you choose to
purchase one), fees associated with the manner in which you
choose to use your GO2Bank Debit Card (if applicable), or fees
for other third party services.
A Refund Transfer is a limited-purpose bank account offered for a

fee, where your tax refund amounts can be deposited, then any
fees and, if applicable, loan repayment amounts that you have
authorized are disbursed to the appropriate parties, and the
remaining amounts (if any) are disbursed to you in the manner you
chose during your tax preparation. A Refund Transfer is intended
What is a Refund Transfer?
for one-time use only to access the refund proceeds and may not
be used on a long-term basis. You may or may not have selected
this service as part of your tax preparation. This service may be
offered by another bank. See your contract documents for further
information.
No. If you did not choose a Refund Transfer from another bank
during your tax preparation, you will obtain a bank account
provided by Civista Bank at no cost to you to receive your tax
Is a Refund Transfer required to get a loan? refund proceeds. FIRST CENTURY will take out the loan
repayment amounts owed to us, and then disburse the remaining
amount (if any) to you in the manner you chose during your tax
preparation.
No, but if you did not elect a Refund Transfer from another bank
during your tax preparation, you will need to obtain a bank account
provided by Civista Bank at no cost to you to receive your tax
Am I required to purchase any other bank refund proceeds. FIRST CENTURY will take out the loan
products to obtain the Refund Advance Loan? repayment amounts owed to us, and then disburse the remaining
amount (if any) to you in the manner you chose during your tax
preparation.
No. The cost to prepare your tax return does not increase if you
If I get a Refund Advance Loan, does the cost
obtain a Refund Advance Loan from FIRST CENTURY.
of my tax return preparation increase?
No. The Refund Advance Loan is optional. You are not required
to apply for any loan to have your tax return completed and filed.
Is any loan required in order to have a tax The IRS and state taxing authorities can issue tax refunds directly
return completed and filed? to you without your having to incur any additional costs for a tax
refund-related product.
No. Whether or not you choose to obtain a Refund Advance

Does getting a loan affect how quickly I receive
Loan has no effect on when you will receive your refund from
a tax refund from the IRS or state taxing
the IRS or state taxing authorities.
authority?
Not unless you have specifically applied for joint credit. However,
If my tax filing status is “married filing jointly,” is even if you have not applied for joint credit, any refund from your
my spouse personally liable for the Refund jointly filed income tax return(s) may be used to repay the Refund
Advance Loan? Advance Loan.
Depending upon underwriting, FIRST CENTURY may approve

your loan amount before the IRS accepts your tax return, or may
If I apply for a loan between January 2, 2023
delay making a decision about your application until after the IRS
and the date upon which the IRS begins to
accepts your tax return. Upon approval, FIRST CENTURY will
accept tax returns, how will I know if FIRST
notify you by text and/or email and advance the Refund Advance
CENTURY approves my application?
Loan amount to you.
If I apply after the IRS begins accepting tax If you apply after the IRS begins accepting tax returns, then we
returns, then how will I know if FIRST cannot approve your application until the IRS accepts your tax
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CENTURY approves my application? returns. Upon approval, FIRST CENTURY will notify you by text
and/or email and advance the Refund Advance Loan amount to
you.
You can select to receive loan proceeds via a GO2Bank Debit

Card, check or by direct deposit to your bank account. FIRST
CENTURY will fund loan proceeds electronically to the GO2Bank
How will I get my loan proceeds? Debit Card received from your tax preparer, or via a check issued
to you available for personal delivery at your tax preparer’s office,
or by electronic deposit to your bank account.
If your 2022 federal and state tax refund(s) are insufficient to pay
the Refund Advance Loan in full after applying such refund
What if my refund(s) are insufficient to pay the
amount(s) to the outstanding balance of the Refund Advance Loan,
Refund Advance Loan in full?
you are not obligated to repay any difference.
Possibly. Some taxpayers meeting certain adjusted gross income

level thresholds may qualify for free software. For more
Is there a free method to electronically file a
information visit https://www.irs.gov/uac/free-file-do-your-federal-
tax return?
taxes-for-free
Yes. If you have an existing deposit account or product into which

a tax refund can be directly deposited, you can file a tax return
Can I file a tax return electronically and receive electronically and receive your refund within a similar time frame
my refund within a similar time frame and and without paying the additional fees associated with a tax refund-
without paying the additional fees associated related product. Obtaining a Refund Advance Loan from FIRST
with a tax refund-related product if I have an CENTURY or purchasing a tax refund-related product from any
existing account into which a tax refund can be other bank has no effect on the timing of your tax refund.
directly deposited? Furthermore, you are not required to obtain any bank product to file
your tax return directly with the IRS or state taxing authorities.
The IRS can send your refund either by check mailed directly to
you through U.S. Mail, by direct deposit to your bank/credit union
What are the payment options for receiving tax
account, to a prepaid card, or by other methods permitted by law.
refunds from the IRS?
For estimated availability of refunds, see the table below.
You can file your tax return by paper and obtain your refund directly from the IRS or a State
for free without obtaining a loan. You may qualify to file your taxes electronically with the IRS
for free if you meet certain adjusted gross income level thresholds. You may consult the IRS
Web site (www.irs.gov) or the applicable tax authority for information about tax refund
processing. The IRS advises the following filing methods, disbursement options, and
estimated delivery of tax refunds available for taxpayers receiving refunds directly from the
IRS:
Filing Method Disbursement Method Estimated Availability of Funds*

Paper Return IRS Issued Check, IRS Direct Deposit, 6 months or more
or IRS Load to a Prepaid Card
E-File IRS Issued Check 21 to 28 days
E-File IRS Direct Deposit Within 21 days
E-File IRS Load to a Prepaid Card Within 21 days
*The estimates shown above do not include any additional time that may be required for your bank to post the
refund to your account, or for mail delivery. The IRS does not guarantee that a person will be paid the full
amount of an anticipated tax refund and does not guarantee that an anticipated tax refund will be deposited
into a person’s account or mailed to a person on a specific date.
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THIS TABLE PROVIDES

REPRESENTATIVE EXAMPLES OF AVAILABLE CREDIT TERMS FOR FIRST CENTURY REFUND ADVANCE
LOANS
Please note that your Refund Advance Loan amount depends primarily on the amount of your expected
federal tax refunds.
ANNUAL
LOAN EXAMPLES PERCENTAGE FINANCE Amount Total of
RATE CHARGE Financed Payments**
$500 Refund Advance Loan 35.99% $15.28 $500 $515.28
$3,000 Refund Advance Loan 35.99% $91.70 $3,000 $3091.70
$7,000 Refund Advance Loan 35.99% $213.97 $7,000 $7213.97
Terms of Repayment - The Refund Advance Loan examples above assume that interest will accrue
for 31 days from the date of your loan funding date because 31 days is the average number of days
that interest accrues on Refund Advance Loans for our customers. Because of COVID-19 and the
possibility of delays in your receipt of your tax refund, this period may be longer and more interest may
accrue before your Refund Advance Loan is repaid. Interest may accrue for as long as 120 days if your
tax refund is delayed. The actual day you receive your 2022 federal (and state, if applicable and
permitted by state law) tax refund(s) would reduce the Finance Charge amount in the above examples
if received prior to 31 days from your loan funding date, and increase the Finance Charge if it is received
after 31 days. In no case will interest accrue on your Refund Anticipation Loan beyond 120 days of your
loan funding date. The IRS estimates 21 days from electronic filing for you to receive your federalrefund.
**Payments Schedule - The Refund Advance Loan is due when you receive your tax refund(s). If you
receive only one tax refund and it is sufficient to repay your Refund Advance Loan, we will automatically
deduct that from your bank account that receives the tax refund and that would be the only payment you
would make. If you receive multiple tax refunds and the first one is not sufficient to repay your Refund
Advance Loan, then the outstanding balance owing will be paid upon receipt of the subsequent tax refund,
if applicable and permitted by state law. If the total amount of your tax refund or refunds is insufficient to
pay the full amount of your Refund Advance Loan, you will not be required to repay the balance remaining
after your tax refund or refunds have been applied to repay your loan.
MILITARY ANNUAL PERCENTAGE RATE DISCLOSURE Federal law provides important protections to
active duty members of the Armed Forces and their dependents relating to extensions of consumer
credit. In general, the cost of consumer credit to a member of the Armed Forces and his or her
dependent may not exceed an annual percentage rate of 36 percent. This rate must include, as
applicable to the credit transaction or account: The costs associated with credit insurance premiums;
fees for ancillary products sold in connection with the credit transaction; any application fee charged
(other than certain application fees for specified credit transactions or accounts); and any participation
fee charged (other than certain participation fees for a credit card account). To hear this same disclosure
and for a general description of your payment obligations for this Refund Advance Loan, call the
following toll‐free number 855‐459‐9226.
313389348.6
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Refund Advance Loan Application

We intend to apply for joint credit:
BLAKE D WEBER
Applicant Co-Applicant
An application for joint credit is not required. If you do not want to apply for joint credit,
provide only your name (as the Applicant) and SSN.
APPLICANT NAME: BLAKE D WEBER SSN: xxx-xx- 0727
CO-APPLICANT NAME (if applicable): SSN: xxx-xx-
Representations. By signing below, you hereby certify and agree as follows:
You are requesting and applying to First Century Bank, N.A. (“FIRST CENTURY,” “we”, “us” and
“our”) to underwrite you for the highest Refund Advance Loan amount we offer.
1. Definitions and Loan Decision. You are requesting and applying to FIRST CENTURY to underwrite
you for the highest Refund Advance Loan amount we offer. Subject to a minimum loan amount of $500
and a maximum loan amount of $7,000, FIRST CENTURY may approve this Refund Advance Loan
application (“Application”) in any amount ranging from $500 to $7,000. FIRST CENTURY may also
decline your Application. If we approve your interest bearing loan request, then we will advise you by
text and/or email (as previously selected, but subject to our discretion to advise you by email) of your
exact Refund Advance Loan amount. If we decline to make a Refund Advance Loan to you, we also
will notify you in this way.
2. Optional Interest-Bearing Loan. You acknowledge that the Refund Advance Loan is an optional credit
product and is not required in order to file your taxes or receive a tax refund. You understand that YOU
WILL INCUR INTEREST CHARGES FOR THE INTEREST BEARING REFUND ADVANCE LOAN.
You acknowledge you have reviewed the costs of the Refund Advance Loan which has an ANNUAL
PERCENTAGE RATE (APR) of 35.99%. You also acknowledge that you have compared the costs of
other sources of credit, and consider the interest bearing Refund Advance Loan to be consistent with
your personal needs and financial circumstances.
3. Loan Proceeds. If approved, you will receive your loan proceeds via:
New GO2Bank Debit Card (obtained in your Tax Preparer’s office). The GO2Bank debit card is issued by Green
Dot Bank (the “GO2Bank Debit Card”) pursuant to your separate request to apply for and obtain such GO2Bank
Debit Card. FIRST CENTURY is not the issuer of the GO2Bank Debit Card.
Card Envelope Number:

Paper Check (obtained in your Tax Preparer’s office).
X
Direct Deposit to bank account number 875103673534
4. Third Party Fees. You may pay fees to other parties for other products that you choose, including (a)
fees to your tax preparer for tax preparation and filing, (b) fees for a Refund Transfer (if you choose
one), or (c) fees for other third-party services such as fees to your GO2Bank Debit Card provider under
your cardholder agreement.
5. Free Filing Options. Some taxpayers meeting certain adjusted gross income level thresholds may
qualify for free tax filing software. For more information visit https://www.irs.gov/filing/free-file-do-your-
federal-taxes-for-free.
6. Authorization to Verify Information and Obtain Credit Reports. You understand and agree that you
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are authorizing us to obtain credit reports and related information about you from one or more
commercial or consumer credit reporting agencies and to verify any information you provide us in
connection with your Application including, but not limited to, your employment and income. We reserve
the right to conduct such verification through third parties. You agree we may contact third parties
without further notice to you to verify any such information. We may use your credit reports to
authenticate your identity, to make credit decisions, and for other related purposes. You authorize us
to obtain your credit reports (at our discretion), including (i) each time you request a loan, (ii) during the
processing or closing of a loan to you, or (iii) at various times during the term of your loan in connection
with the servicing, monitoring, collection or enforcement of the loan. Upon your request, you will be
informed whether or not we have requested your credit report and, if so, the name and address of the
agency that furnished the report.
7. Sharing Information, US Department of Treasury Offset, No Setoff of Past Due Debt. You
authorize and consent to our sharing your nonpublic personal information including without limitation
your tax return information with (a) third party service providers to the extent necessary to process your
product request, (b) your tax preparer, and its affiliates, (c) other third parties who are performing
essential duties on behalf of FIRST CENTURY, and (d) if applicable, the bank holding the deposit
account receiving your federal and/or state tax refunds to the extent necessary to underwrite,
administer, service and process your loan. This sharing is not subject to your right to opt out. You
acknowledge that you have instructed your tax preparer to share information regarding your tax return
with us. You authorize us to contact the US Department of Treasury, Bureau of the Fiscal Service
Treasury Offset Program call center on your behalf in connection with our review of your Application for
the Refund Advance Loan, and to disclose the information you have provided in the Application to the
US Department of Treasury, Bureau of the Fiscal Service, and to obtain any and all information related
to debt owed by you or the Joint Filer to the United States Government, to a State, or any debt enforced
by a State, including child support obligations and/or any payments made or due to you by a Federal
or State agency, and/or any tax return information disclosed to the Internal Revenue Service in order
to collect tax debt through the levy process under 26 U.S.C. §6331(h), and to conduct tax refund offset
under 26 U.S.C. §6402. This authorization extends to any automated system or by any other written,
electronic or telephonic means and is valid for one year from the date of this Agreement. You
acknowledge that by applying for the Refund Advance Loan, you have not authorized us to deduct any
amounts necessary to repay any past-due debt from your refund.
8. Repayment and Refund Processing. You agree that your federal (and state, if applicable and
allowable under state law) tax refund(s) may be used to repay the Refund Advance Loan. You may
consult the IRS Web site (www.irs.gov) or the applicable tax authority for information about tax refund
processing.
9. Communications, Change of Address and Other Information. You must send all written notices to
us at the Customer Service Address: FIRST CENTURY Customer Service, Attn: Fast Cash Advance
Refund Loan, P.O. Box 23679, Hilton Head Island, SC 29925-3679. You should direct all phone calls
to the Toll-Free Customer Service Number: (855) 459-9226. To the extent permitted under applicable
law, any written or email correspondence you send to us will not be effective until we receive and have
had a reasonable opportunity to act on such correspondence. However, any written or email
correspondence we send you will be effective and deemed delivered when mailed to you at your mailing
address (or your email address if you have authorized electronic communications) as it appears on our
records. You must notify us of any changes to your name, mailing or email address, home, cell or
business phone number within 15 days of any change. We will rely on your contact information as it
appears on our records for any and all communications we send to you unless and until either you or,
in the case of your mailing address, the U.S. Postal Service notifies us of a change of address and we
have had a reasonable opportunity to act on such notice.
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10. Telephone Monitoring and Recording. You agree that we may monitor, record, retain and reproduce
your telephone calls and any other communications you provide to us, regardless of how transmitted to
us, for training and quality control purposes and as evidence of your authorization to act in connection
with the Refund Advance Loan. However, we are not under any obligation to monitor, record, retain or
reproduce such items, unless required to do so by applicable law.
11. Account Related Communication. You authorize us to contact you using automatic telephone dialing
systems, artificial or prerecorded voice message systems, text messaging systems and automated
email systems in order to provide you with information about your loan. You authorize us to make such
contacts using any telephone numbers (including wireless, landline and VOIP numbers) or email
addresses you supply to us in connection with your loan Application or loan agreement, the servicing
of amounts you owe, or any other loan-related matter. Message and data rates may be imposed by
your mobile, wireless, or Internet carrier. To stop text messages, you can simply reply “STOP” to any
text message we send you. To stop emails, you can follow the opt-out instructions included at the
bottom of the emails.
12. Privacy Policy. We respect your privacy of information relating to the Refund Advance Loan and
encourage you to read our Privacy Policy. Changes may be made to our Privacy Policy from time to
time and we will provide you with any notice of such changes required by applicable law. Our current
Privacy Policy is available at https://myfirstcenturybank.com/wp-content/uploads/2021/09/First-
Century-Bank-Privacy-Policy-2020-07_NEW.pdf
13. Waiver of Right to Trial by Jury and Arbitration Agreement. You agree that the Waiver of Right to
Trial by Jury and Arbitration Agreement set forth below is incorporated herein by reference and
governs disputes or claims between us as set forth therein.
14. Representations and Acknowledgements. You are not a debtor under any proceeding in
bankruptcy and have no intention to file a petition for relief under any chapter of the United States
Bankruptcy Code. You have read, understand, and agree to all of the terms of this Application. You
certify that the information you have provided to us and your tax preparer prior to signing this
Application is true and accurate. You acknowledge that you are applying for the Refund Advance
Loan of your own free will and are not relying on any recommendation from your tax preparer or any
other party as to its suitability for your financial situation. You affirm that you have chosen your tax
preparer for your own reasons and/or convenience, without our recommendation or endorsement.
You absolve and will not hold us liable should your tax preparer make a mistake in the computation of
your tax return(s) or make any other error or omission in submitting the same, or should your tax
preparer fail to deliver a GO2Bank Debit Card or check to you.
15. Additional Certification. You hereby certify that: (a) you are not delinquent in the payment of taxes,
either individual or business, to the IRS or any state agency; (b) you are not delinquent in the payment
of any child support or alimony; (c) you are not delinquent in the payment of any student loans, Veteran
Administration loans or other Federally sponsored loans; (d) you have not previously filed a 2022 federal
income tax return; (e) you have not paid any estimated tax and/or did not have any portion of your 2021
refund applied to your 2022 taxes; (f) you are of legal age to enter into contracts in the State where you
reside; (g) you do not have a power of attorney presently in effect or on file with the IRS to direct your
federal tax refund to any third party; (h) you are not presently making regular payments or are delinquent
in making such payments to the IRS for unpaid taxes in prior years; and (i) you do not have a bankruptcy
petition filed nor do you anticipate filing a bankruptcy petition.
16. Application Denial. We may decline your Application based on our underwriting standards including
without limitation a review of information from the Internal Revenue Service or US Department of
Treasury, Bureau of the Fiscal Service, such as if you, and if applicable your spouse, have delinquent
child support or outstanding unpaid taxes, student loans, or other federal debt or a review of information
contained in your credit report(s) or an inability to verify your identity. We will notify you of our decision.
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USA PATRIOT ACT DISCLOSURE: To help the government fight the funding of terrorism and money
laundering activities, Federal law requires all financial institutions to obtain, verify, and record information
that identifies each person who obtains a loan. What this means for you: When you apply for a loan, we will
ask for your name, address, date of birth, and other information that will allow us to identify you. We may
also ask to see your driver’s license or other identifying documents.
STATE DISCLOSURES: Ohio Residents: Ohio laws against discrimination require that all creditors make
credit equally available to all credit-worthy customers and that credit-reporting agencies maintain separate
credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance
with this law. Wisconsin Residents: No provision of a martial property agreement, unilateral statement
under Section 766.59 of the Wisconsin Statutes, or court order under Section 766.70 of the Wisconsin
Statutes adversely affects the interest of the creditor unless the creditor, prior to the time the credit is
granted, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse
provision when the obligation to the creditor is incurred. If you are married, by submitting your credit
application you are confirming that this credit obligation is being incurred in the interest of your marriage
and your family. California Residents: Married applicants may apply for separate credit. All States:
Taxpayers filing jointly may apply for individual credit.
ELECTRONIC SIGNATURE DISCLOSURE & CONSENT
By signing and submitting this Application, you are providing your consent for First Century Bank, N.A. to
provide required disclosures to you electronically as described below (your “Consent”).
Communications to be Provided Electronically. Your Consent for electronic delivery applies to all
required disclosures, notices and agreements relating to your Refund Anticipation Loan and application
for that loan (“Required Information”). Required Information includes:
• notice to you of whether your Refund Anticipation Loan application has been approved,
• your Refund Anticipation Loan agreement,
• Truth in Lending disclosures,
• error resolution notices and communications,
• change in terms notices, and
• all other notices and disclosures that we are required to provide to you regarding your Refund
Anticipation Loan.
With this Consent, we can deliver Required Information to you by: a) displaying or delivering the
Required Information electronically, including by email; and b) requesting that you print or download the
Required Information and retain it for you records.
You understand that by giving us your Consent, you may no longer receive paper copies of
communications and you accept any consequence of not reviewing communications in a timely manner.
Accordingly, you should print or otherwise retain a copy for your records of all disclosures you receive
electronically.
Receiving Paper Copies and Withdrawing Consent. At your request, we will provide you with paper
copies of communications that are provided to you electronically. You also may elect to withdraw your
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Consent for electronic communications at any time free of charge by doing one of the following:
• Electronically by emailing:contactus@myfcbusa.com
• By calling our Service Provider at 855-459-9226 (“Toll-Free Customer Service Number”).
By using one of the methods above, you may also contact us to receive a paper copy of any electronic
communication or if you need to update any personal information. We retain copies of communications
for the time periods required by law and will provide you with copies of these free of charge, upon your
request, within those time periods.
Hardware and Software Requirements. In order to access, view, and retain the Required Information
that we provide to you electronically, you must have:
• a computer or other device with access to the Internet,

• an e-mail account,
• a web browser that supports HTML and 128-bit encryption such as Chrome, Firefox, Internet
Explorer or Safari,
• the capability to download and print the Required Information that we send to you electronically,
and
• a program to view PDF files (such as Adobe Reader, which you may download free from
http://get.adobe.com/reader/).
We may amend (add to, delete or change) the terms of this Consent to electronic communication by
providing you with advance notice.
By providing this Consent, you confirm that you have read the information about the use of
electronic records, disclosures, and notices and you consent to the use of electronic records for
the delivery of “Required Information” in connection with our relationship. You also confirm that
you meet the Hardware and Software Requirements described above. You also consent to the use
of electronic records and electronic signatures in place of written documents and handwritten
signatures; and you confirm that you are authorized to, and do, consent on behalf of all the other
account owners, authorized signers, authorized representatives, delegates, product owners
and/or service users identified with your First Century Bank, N.A. products.
Applicant’s Signature: Date: 03/14/2023 SSN: XXX-XX- 0727
Print Name: BLAKE D WEBER
Other Signature (Where Applicable): Date: SSN: XXX-XX-
Print Name:
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Fast Cash Advance Refund Advance Loan Agreement

(Interest-Bearing)
CONTACT INFORMATION:
Creditor Name: First Century Bank, N.A.
Customer Service Address: P.O. Box 23679, Hilton Head Island, SC 29925-3679
Customer Service Phone Number: (855-459-9226)
By signing below, and meeting our underwriting criteria, we may fund this Refund Advance Loan Agreement
subject to the terms set forth herein.
FEDERAL TRUTH-IN-LENDING DISCLOSURE
THIS TRUTH-IN-LENDING DISCLOSURE APPLIES TO YOU
ANNUAL FINANCE Amount Total of

PERCENTAGE (e) (e)
RATE CHARGE(e) Financed Payments
The cost of your The dollar amount The amount of credit The amount you will have
credit as a yearly the credit will cost provided to you or on paid after you have made
rate. you. your behalf. all payments as scheduled.
35.99% $61.13 $2,000.00 $2,061.13
Payment Schedule(e): One payment in the amount of the first 2022 tax refund you receive or the
Total of Payments, whichever is less, is due on the earlier of (i) the day you receive your 2022 state tax
refund(s), only if applicable and permitted by state law; or (ii) the day you receive your 2022 federal tax
refund. However, if (i) you will receive more than one tax refund, (ii) the first tax refund you receive
does not pay your loan in full, and (iii) state law permits repayment from your state tax refund, then a
second payment in the amount of the outstanding balance is due on the day you receive your second
tax refund.*
Security: You are giving us a security interest in your 2022 federal tax refund and, to the extent
applicable and permitted by state law, state tax refund(s).
Prepayment: If you pay off early, you will not have to pay a penalty. A prepayment penalty may not be
imposed for paying all or part of the principal balance before the date on which the principal is due.
See your contract documents for any additional information about nonpayment, default, and any
required repayment in full before the scheduled date, and prepayment refunds and penalties.
(e) means an estimate
Itemization of Amount Financed of $2,000(e)
Amount given to you directly: $2,000.00(e)
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Estimated Disclosure Information: The estimates in the Truth-in-Lending table above and in the
Itemization of Amount Financed assume that you will be approved for a Refund Advance Loan in the amount
of $2,000. However, if you are approved, the actual amount of your Refund Advance Loan could be as low
as $500 or as high as $7,000. If you are approved for a Refund Advance Loan for $7,000, your Amount
Financed would be $7,000; your Finance Charge would be $213.97; and your Total of Payments would be
$7,213.97. If you are approved for a Refund Advance Loan for more than $2,000 but less than $7,000, these
amounts would be higher than for a $2,000 loan but lower than for a $7,000 loan.
The estimated Finance Charge, Total of Payments, and Payment Schedule also assume that you will repay
your Refund Advance Loan in 31 days, which is the average length of time our customers take to repay
their Refund Advance Loans. Because of COVID-19 and the possibility of delays in your receipt of your tax
refund, this period may be longer and more interest may accrue before you Refund Advance Loan is repaid.
Interest may accrue for as long as 120 days if your tax refund is delayed. The actual day you receive your
2022 federal (and state, if applicable and permitted by state law) tax refund(s) would reduce the Finance
Charge amount in the above examples if received prior to 31 days from your loan funding date, and increase
the Finance Charge if it is received after 31 days. Changes to the Finance Charge would also change your
Total of Payments and the Payment Schedule estimated above. However, in no case will interest accrue on
your Refund Anticipation Loan beyond 120 days of your loan funding date.
* The IRS estimates you will receive your federal refund within 21 days from electronic filing.
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FAST CASH REFUND ADVANCE LOAN AGREEMENT
1. Introduction and Definitions. This FIRST CENTURY Refund Advance Loan Agreement (the “Loan
Agreement”) contains important terms, conditions and disclosures about your Refund Advance Loan
and the services of First Century Bank, N.A. (“FIRST CENTURY”). The term “Loan Agreement” means
this Refund Advance Loan Agreement, which incorporates by reference all of the provisions in the FIRST
CENTURY Refund Advance Loan Disclosure, Application, and Mutual Dispute Resolution and
Arbitration Agreement and Class Action Waiver. Read this Agreement carefully before agreeing to
it, and print a copy and retain it for future reference. As used in this Loan Agreement, and except as
provided in the “Limited Purpose Joint Tax Filer Agreement” below, the words “you,” “your” and
“Applicant” refer to the primary applicant and any joint applicant for a Loan from FIRST CENTURY. The
words “FIRST CENTURY,” “we,” “us,” and “our” mean First Century Bank, N.A. and its successors and
assigns.
You understand that by agreeing to this Agreement you are requesting a Loan from FIRST CENTURY
and that you will receive a text and/or email (as previously selected, but subject to our discretion to
advise you by email) from FIRST CENTURY telling you if you have been approved for the Loan and the
amount of the Loan. The words “Refund Deposit Bank” mean the financial institution holding the deposit
account into which you direct your federal and if applicable state tax refund(s) to be deposited (“Refund
Deposit Account”).
2. Your Expected 2022 Tax Refund(s). You acknowledge and agree that your tax preparer has prepared
your 2022 tax return, and that you have delivered to your tax preparer true and accurate financial
information regarding your taxable income and tax situation for 2022. You understand that purchase of
a Refund Transfer is not required for you to apply for, or be approved for, a Refund Advance Loan.
Choices made pursuant to a Refund Transfer Agreement will not change or affect the terms of your
Refund Advance Loan. You acknowledge that receiving this Refund Advance Loan has no impact
or effect upon the timing of receiving your tax refund. If your federal income tax refund is paid by
the IRS before the Refund Advance Loan is funded, your Refund Advance Loan will not be approved
and the Refund Advance Loan will not be funded.
3. Status of Application; Approval and Funding of Loan. The amount of the loan for which you will
qualify will depend, in part, on the amount of your estimated income tax refund. We have not yet
committed to make any loan. We will only be committed to make a loan if and when we issue
loan proceeds to you in the manner set forth below. Based on your representations made during
the application process and in this Loan Agreement, we agree as follows. If your Application is approved
and all conditions to funding are met, we will advise you of the final approved amount of your Refund
Advance Loan. We will deliver the approved loan amount to the disbursement option you chose during
your tax preparation: either (i) a GO2Bank Debit Card, (ii) a check issued in your tax preparer’s office,
or (iii) direct deposit to your bank account. In the event you receive funds from us that (i) exceed the
amount of your Loan or (ii) are credited to you in error, you agree to immediately repay such amount
and agree that we may debit your Refund Deposit Account in the amount of such overpayment or error.
4. Promise to Pay, Interest, Estimates and Security. You promise to pay us the principal amount of loan
advance to you, plus simple interest calculated on the outstanding principal balance as set forth herein.
We earn interest at the daily rate of .09860% (35.99% APR), on the outstanding principal balance,
beginning on the date that the loan proceeds are disbursed to you, and continuing thereafter until the
loan advance and fees are fully repaid up to a maximum of 120 calendar days. If state law does not
permit repayment of the Refund Advance Loan from the state tax refund or you do not receive a state
refund, then the Refund Advance Loan shall be repaid solely from your federal tax refund. If state law
allows repayment of the Refund Advance Loan from the state tax refund and the amount of the first tax
refund you receive is insufficient to pay your obligations in full under this Loan Agreement, then you
agree to pay us the outstanding balance owing upon receipt of the subsequent tax refund. Therefore,
you promise to pay us the outstanding balance or the amount of your first tax refund, whichever is less,
on the earlier of (i) the day you receive your 2022 state tax refund(s), only if applicable and permitted by
state law; or (ii) the day you receive your 2022 federal tax refund. If (i) you will receive more than one
tax refund, (ii) the first tax refund you receive is insufficient to pay your loan in full, and (iii) state law
permits repayment from your state tax refund, then a second payment in the amount of the outstanding
balance is due on the day you receive your second tax refund. Your total interest charges depend on
when you make payments on your Refund Advance Loan. Early payment and partial early payments
may decrease the amount of interest you owe. Payments made later in time may increase the amount
of interest you owe, but the interest charged hereunder will cease to accrue after 120 days from your
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loan funding date. If a partial payment is received, such payment will be applied first to principal, then to
unpaid interest. We have made our estimated “Amount Financed” disclosure in good faith based upon
the amount we believe you will receive in loan proceeds. In addition, the U.S. Department of Treasury
estimates the IRS will disburse your 2022 tax refund within 21 days of electronically filing. We have
made the estimated “Annual Percentage Rate, Finance Charge, Total of Payments and Payment
Schedule” disclosure based on an estimate of 31 days of interest accrual because that is the average
number of days that our customers take to repay their Refund Advance Loans. You grant us a security
interest in your 2022 Tax Refunds (as defined below) if applicable and permitted by state law.
5. Refund Deposit Account and Repayment from Refunds. You represent and warrant to us that you
have or will authorize and direct the Refund Deposit Account Bank to electronically transfer funds from
the Refund Deposit Account (i) to us in a sufficient amount automatically on the date(s) you receive your
2022 federal tax refund (and state tax refund, if applicable and permitted by state law), in one, or if
applicable and permitted by state law, more than one transfer to pay the Refund Advance Loan, and (ii)
to disburse any remaining 2022 Tax Refunds (as defined below) balance after the loan is repaid (and
after any other payments you have authorized have been made) to you according to the disbursement
option you selected. Your Refund Advance Loan will be repaid solely from your 2022 federal and, if
applicable and permitted by state law, state tax refunds (“2022 Tax Refunds”). If your 2022 Tax Refunds
are insufficient to pay the loan in full after applying such refund amount(s) to the outstanding balance of
the loan, you are not obligated to repay any difference; provided, however, if your 2022 Tax Refund is
paid to you by any means other than by direct deposit to Refund Deposit Account Bank, you will be
required to repay the amount of the loan (up to the total of your 2022 Tax Refund) by direct payment to
us via certified funds or money order to First Century Bank, N.A., Attn: RAD Payoff, P.O. Box 23679,
Hilton Head Island, SC 29925-3679. Repayment of this Refund Advance Loan solely from your 2022
Tax Refunds thereby reduces the amount you can expect to receive from such refunds.
6. Right to Rescind, Prepayment, and Default. You may cancel your Refund Advance Loan at any time
before any loan proceeds are disbursed to you by calling 855-459-9226 and requesting a cancellation.
Residents of Michigan, Minnesota, Tennessee, Virginia or Washington may cancel this Loan as provided
in the separate disclosure that we provided to you. You will not incur a fee, charge or penalty if you
request to rescind your Refund Tax Loan before proceeds of the Refund Advance Loan are disbursed
to you. Thereafter, you may prepay this loan in full or in part and will be liable only for the interest that
has accrued on the amount of your prepaid amount up until the time of your prepayment. You will be in
default if you break any promise in this Loan Agreement. We may at any time and in our sole discretion
delay enforcing or choose not to enforce any of our rights or remedies under this Loan Agreement or
under applicable law without losing any of those or any other rights or remedies. Even if we do not
enforce our rights or remedies at any one time, we may enforce them at a later date.
7. Severability and Third-Party Claims. You agree that if any part of this Loan Agreement is declared
invalid, the rest of the Loan Agreement remains valid. Except as required by applicable law, we will not
be responsible for any claim you may have against any third party that provides you with goods or
services in connection with this Loan Agreement. You agree this Loan Agreement, if a Loan is funded,
becomes the final agreement between the parties, and that any change to this Loan Agreement must
be in writing, and signed by both parties.
8. Governing Law. The enforcement and interpretation of this Agreement and the transactions
contemplated herein (including, without limitation, the applicable interest rate) shall be governed by
applicable federal law, including without limitation the Federal Arbitration Act as set forth in the Mutual
Dispute Resolution and Arbitration Agreement and Class Action Waiver, and, to the extent not
preempted by federal law, the laws of the State of South Carolina, without regard to the conflicts of laws.
9. Security Interest and Assignment. You hereby assign to First Century your 2022 federal income tax
refund to the extent necessary to reimburse First Century for your Loan. To the extent permitted by state
law, you also grant First Century a security interest in your 2022 state income tax refund to the extent
necessary to reimburse First Century for your Loan. You may not revoke this security interest or any
assignment.
10. Miscellaneous. (a) The provisions in this Agreement survive the approval of your application for a Loan
and the disbursement of any Loan and any income tax refund proceeds to you. (b) You agree that First
Century may assign, sell or transfer this Agreement, our security interest, our ownership of any Loan
you received under this Agreement, and all or part of our rights arising under this Agreement to a third
party or affiliate of First Century and that First Century may make any transfers necessary to accomplish
the assignment, sale or transfer.
11. MUTUAL DISPUTE RESOLUTION AND ARBITRATION AGREEMENT AND CLASS ACTION
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WAIVER. For purposes of this Mutual Dispute Resolution and Arbitration Agreement and Class Action
Waiver (the “Agreement and Waiver”), “FIRST CENTURY” includes its service providers in connection
with the loan program. THIS SECTION 11 SHALL NOT APPLY TO ACTIVE DUTY MEMBERS OF THE
ARMED FORCES OR THEIR DEPENDENTS.
A. Dispute Resolution. You and FIRST CENTURY agree to submit to informal resolution and, if
necessary, to arbitration, any and all disputes or controversies with the other party arising from or
relating in any manner to the Loan program, your Loan, or this Agreement (whether a direct claim,
counterclaim, cross-claim or third-party claim) (for purposes of this Agreement and Waiver, “Claim”
or “Claims”) in accordance with the terms of this Agreement and Waiver. Claims may include, but
are not limited to: (a) Claims based upon contract, tort, fraud or other intentional torts (whether
arising under any federal or state law or common law); and (b) Claims concerning the enforceability,
applicability or formation of any aspect of the Agreement, including this Agreement and Waiver.
B. Informal Resolution. If you wish to assert any Claim against FIRST CENTURY, you agree to provide
FIRST CENTURY with a brief, written description of the Claim and your contact information by email
to contactus@myfcbusa.com, and give us 30 days within which to resolve the Claim to your
satisfaction. If we do not resolve the Claim through good faith negotiations under this informal
process, you may pursue the Claim in accordance with the arbitration agreement below.
C. Arbitration of Disputes. Any arbitration hereunder shall be administered by the American Arbitration
Association (“AAA”) in accordance with its Commercial Arbitration Rules and, if applicable, the
Supplementary Procedures for Consumer-Related Disputes, as well as the provisions of this
Agreement and Waiver. In the event of any inconsistency between the AAA Rules and this
Agreement and Waiver, the terms of Agreement and Waiver shall apply unless the arbitrator
determines otherwise. You may obtain a copy of the rules and procedures for AAA by contacting the
AAA at 877.495.4185 or by visiting its website at www.adr.org. Alternatively, any dispute otherwise
subject to arbitration under this Agreement and Waiver may, at the option of the claiming party, be
submitted for adjudication in a small claims tribunal, provided that all claims by all parties in the
dispute fall within the jurisdiction of the small claims tribunal.
D. Class Action Waiver. You agree to initiate or maintain any Claim solely in your individual capacity,
on your own behalf, in an individual arbitration or small claims proceeding, and not as a plaintiff,
class representative, class member or private attorney general in any purported class action or
representative proceeding. You acknowledge and agree that by your submission and FIRST
CENTURY’s consideration of your Application, YOU ARE GIVING UP ANY RIGHT TO SERVE AS
A CLASS REPRESENTATIVE OR AS A MEMBER OF ANY CLASS OF CLAIMANTS OR AS A
PRIVATE ATTORNEY GENERAL IN ANY LAWSUIT, ARBITRATION OR OTHER PROCEEDING
FILED AGAINST FIRST CENTURY.
E. Payment of Arbitration Fees. Regardless of who demands arbitration, FIRST CENTURY will pay the
Arbitrator Fees in full, in addition to the AAA Administrative Fees and Case Service Fees to the
extent required by the AAA Supplementary Procedures for Consumer-Related Disputes, provided,
that if the arbitrator determines that one or more of your Claims is frivolous, the arbitrator shall in the
Final Award require you to pay or reimburse to FIRST CENTURY all AAA and arbitrator fees related
to the frivolous Claims. Except as otherwise provided in this Agreement and Waiver, each party is
responsible for its own costs and fees in the arbitration as provided for in the applicable AAA Rules.
F. Federal Arbitration Act Applies. This Agreement and each of its parts evidence a transaction
involving interstate commerce, and the Federal Arbitration Act (9 USC §1, et. seq.) will apply in all
cases and govern the interpretation and enforcement of the arbitration rules and arbitration
proceedings. Judgment on the award rendered by the arbitrator may be entered in any court of
competent jurisdiction.
G. No Class or Collective Arbitration. You and FIRST CENTURY agree that the arbitrator will not have
the power to conduct any form of class or collective arbitration nor join or consolidate claims by or
for individuals. IN NO CASE SHALL CLASS OR COLLECTIVE ARBITRATION BE PERMITTED
WITH RESPECT TO ANY CLAIM. If, for any reason, the class action waiver agreed to in this
Agreement and Waiver is unenforceable in whole or in part, any Claims that proceed on a class or
collective basis shall be brought and decided in court, and any Claims that proceed on an individual
basis, including Claims by individuals who are not members of a certified class, shall be brought and
decided in arbitration.
H. Notice. FIRST CENTURY shall send any demand or correspondence related to a demand to the
last address for you in FIRST CENTURY’s files. You must send any demand or correspondence
313389348.6
621466
related to a demand to FIRST CENTURY at FIRST CENTURY, P.O. Box 23679, Hilton Head Island,
SC 29925-3679. Any demand or correspondence related to a demand sent to any other person or
location of FIRST CENTURY will not be effective under this Agreement and Waiver.
I. Location of Arbitration Hearing. As provided for in the AAA Supplementary Procedures for
Consumer-Related Disputes, claims may be resolved by the submission of documents (“Desk
Arbitration”) or by telephone hearing. If an in-person arbitration hearing is held, unless otherwise
agreed to by you and FIRST CENTURY, you may elect for the arbitration hearing to be conducted
(a) in the county of your residence, (b) within 30 miles of such county or (c) in the county in which
you completed the Application. If you do not elect a location for the arbitration hearing, the location
shall be chosen by the arbitrator from among the options described in this Paragraph 9.
J. Attorneys’ Fees and Expenses. If allowed by statute or applicable law, the arbitrator may award
your reasonable attorneys’ fees and expenses. FIRST CENTURY agrees that it will not seek to
recover its attorneys’ fees and expenses.
K. The arbitrator, and not any federal, state or local court or agency, will have exclusive authority to
resolve any dispute relating to the interpretation, applicability, enforceability or formation of this
Agreement including, but not limited to, any claim that all or any part of this Agreement is void or
voidable.
I understand that, notwithstanding my acceptance of this Mutual Dispute Resolution and Arbitration
Agreement and Class Action Waiver, above, I may still reject it by sending to FIRST CENTURY a signed
writing (“Rejection Notice”) that is received by FIRST CENTURY within thirty (30) calendar days after
the date I sign this Application. The Rejection Notice must be mailed to FIRST CENTURY at P.O. Box
23679, Hilton Head Island, SC 29925-3679. The Rejection Notice must identify the transaction involved and
must include my name, address, and social security number and must be signed by all persons signing this
Application as Applicant(s). I may send the Rejection Notice in any manner I see fit as long as it is received
at the specified address within the specified time. If the Rejection Notice is sent on my behalf by a third
party, such third party must include evidence of his or her authority to submit the Rejection Notice on my
behalf. No other methods can be used to reject the Mutual Dispute Resolution and Arbitration Agreement
and Class Action Waiver.
DO NOT SIGN THIS LOAN AGREEMENT UNTIL YOU REVIEW EACH OF THE FREQUENTLY ASKED
QUESTIONS ABOVE. CALL (855) 459-9226 IF YOU STILL HAVE QUESTIONS ABOUT THIS LOAN.
YOU ACKNOWLEDGE AND AGREE THAT YOU ARE RECEIVING A LOAN WHICH CHARGES
INTEREST, AND THE MONEY YOU ARE RECEIVING FROM THIS LOAN IS NOT YOUR TAX REFUND.
YOU FURTHER ACKNOWLEDGE THAT RECEIVING A LOAN FROM US HAS NO EFFECT ON THE
TIMING FOR RECEIVING YOUR TAX REFUND. THAT IS, YOU WILL NOT RECEIVE YOUR TAX
REFUND “FASTER” OR “QUICKER” BY OBTAINING A LOAN FROM US. IF YOUR APPLICATION IS
DENIED, YOU WILL STILL RECEIVE YOUR TAX REFUND IN THE MANNER YOU CHOSE DURING TAX
PREPARATION. NOTE THAT ANY FEES YOU PAID TO YOUR TAX PREPARER FOR YOUR TAX
PREPARATION WILL NOT BE REFUNDED.
NOTICE TO CONSUMER: 1. DO NOT SIGN THIS LOAN AGREEMENT BEFORE YOU READ IT OR IF IT
CONTAINS ANY BLANK SPACES. 2. YOU ARE ENTITLED TO AN EXACT COPY OF THIS PAPER. 3.
YOU MAY PREPAY THE UNPAID BALANCE AT ANY TIME WITHOUT PENALTY AND MAY BE
ENTITLED TO RECEIVE A REFUND OF UNEARNED CHARGES IN ACCORDANCE WITH THE LAW.
Borrower’s Signature: Date: 03/14/2023 Borrower’s SSN: XXX-XX- 0727

Print Name: BLAKE D WEBER
Co-Borrower’s Signature (where applicable): Date:

Co-Borrower’s SSN: XXX-XX-
Print Name:
NOTE: If a joint tax return is being filed, and you have

not applied for joint credit with your spouse, the Joint
Filer (your spouse) must sign the Limited Purpose
Joint Tax Filer Agreement on the following page.
313389348.6
Limited Purpose Married Joint Tax Filer AGREEMENT
For purposes of this LIMITED PURPOSE MARRIED JOINT TAX FILER AGREEMENT (“SPOUSE
AGREEMENT”), the words “we”, “us” and “our” mean First Century Bank, N.A. The words “you” and “your”
mean the spouse of the tax preparation customer applying for the Refund Advance Loan and signing the
Refund Advance Loan Agreement above.
Please review this SPOUSE AGREEMENT and sign and complete the information requested on the lines below
if:
(1) you have not applied for joint credit with your spouse for the Refund Advance Loan and
(2) your filing status is married filing jointly and your spouse is applying for the Refund Advance Loan (a
“Joint Filer”). Do not sign this SPOUSE AGREEMENT if you have applied with your spouse for joint credit.
By signing below, you acknowledge and agree that:
• You are not applying for the Refund Advance Loan;

• You are not agreeing to be, and will not be held, personally liable for the Refund
Advance Loan received by your spouse;
• If your spouse’s application is approved, then any refund from your jointly filed income tax
return(s) may be used to repay the Refund Advance Loan;
• You authorize us to contact and disclose information to the US Department of the Treasury,
Bureau of the Fiscal Service Treasury Offset Program call center as part of the application,
and to obtain any and all information related to debt owed by you to the United States
Government, to a State, or any debt enforced by a State, including child support obligations
and/or any payments made or due to you by a Federal or State agency, and/or any tax return
information disclosed to the Internal Revenue Service in order to collect tax debt through the
levy process under 26 U.S.C. §6331(h), and to conduct tax refund offset under 26 U.S.C.
§6402. This authorization extends to any automated system or by any other written,
electronic or telephonic means and is valid for one year from the date of this agreement. You
will complete and sign all documents necessary to obtain such information from the US
Department of Treasury, Bureau of the Fiscal Service Treasury Offset Program;
• You grant us a security interest in any 2022 federal and, if applicable and permitted by state
law, state tax refund(s) from your jointly filed tax return to repay the Refund Advance Loan
received by your spouse;
• You agree that you have received a copy of our Privacy Policy; and
• The Waiver of Right to Trial by Jury and Arbitration Agreement set forth above is
incorporated herein by reference and governs disputes or claims against us relating to this
SPOUSE AGREEMENT.
Joint Filer’s Signature: Joint Filer’s SSN: XXX-XX-
Print Name:
313389348.6
Revised: 07/01/2020
Privacy Policy
FACTS WHAT DOES FIRST CENTURY BANK, N.A.

DO WITH YOUR PERSONAL INFORMATION?
WHY? Financial companies choose how they share your personal information. Federal law gives
consumers the right to limit some but not all sharing. Federal law also requires us to tell you
how we collect, share, and protect your personal information. Please read this notice careful-
ly to understand what we do.
WHAT? The types of personal information we collect and share depend on the product or service you
have with us. This information can include:
 Social Security number and income
 Account balances and payment history
 Credit history and credit scores
When you are no longer our customer, we continue to share your information as described in
this notice.
HOW? All financial companies need to share customers’ personal information to run their everyday
business. In the section below, we list the reasons financial companies can share their cus-
tomers’ personal information. The reasons First Century Bank chooses to share; and whether
you can limit this sharing.
Reasons we can share your personal information Does First Century Can you limit this
Bank Share? sharing?
For our everyday business purposes – such as to process your Yes No
transactions, maintain your account(s), respond to court orders and
legal investigations, or to report to credit bureaus
For our marketing purposes – to offer our products and services to Yes No
you
For joint marketing with other financial companies No We do not share
For our affiliates’ everyday business purposes – information about No We do not share
your transactions and experiences
For our affiliates everyday business purposes – information about No We do not share
your creditworthiness
For our affiliates to market to you No We do not share
For nonaffiliates to market to you No We do not share
Questions? Phone: 800-335-9973; Email: info@myfirstcenturybank.com;

Web: www.myfirstcenturybank.com
313389348.6
Page 2
WHO WE ARE
Who is providing this notice? First Century Bank, N.A.
1731 N. Elm Street
Commerce, GA 30529
WHAT WE DO
How does First Century Bank To protect your personal information from unauthorized access and
protect my personal information? use, we use security measures that comply with federal law. These
measures include computer safeguards and secured files and build-
ings. We also maintain other physical, electronic and procedural
safeguards to protect this information and we limit access to those
employees for whom access is appropriate.
How does First Century Bank We collect your personal information, for example, when you
collect my personal information?  Open an account or deposit money
 Pay your bills or apply for a loan
 Use your credit or debit card
We also collect your personal information from others, such as cred-
it bureaus, affiliates, or other companies.
Why can’t I limit all sharing? Federal law gives you the right to limit only
 Sharing for affiliates’ everyday business purposes – infor-
mation about your creditworthiness
 Affiliates from using your information to market to you
 Sharing for nonaffiliates to market to you
State laws and individual companies may give you additional rights
to limit sharing.
DEFINITIONS
Affiliates Companies related by common ownership or control. They can be financial and
nonfinancial companies.
 First Century Bank does not share with our affiliates.
Nonaffiliates Companies not related by common ownership or control. They can be financial and
nonfinancial companies.
 First Century Bank does not share with nonaffiliates so they can market to
you.
Joint Marketing A formal agreement between nonaffiliated financial companies that together
market financial products to you.
 First Century Bank does not jointly market.
Please Recycle
313389348.6
TENNESSEE, VIRGINIA AND WASHINGTON DISCLOSURE
FOR REFUND ANTICIPATION LOAN (RAL)
The table below provides examples of the Annual Percentage Rate (APR) for Refund
Anticipation Loans in the amounts we offer to qualifying customers. A Refund Advance Loan
arranged for $500 to $7,000 has an ANNUAL PERCENTAGE RATE (“APR”) of 35.99%.
Examples below are based on sample loan amounts. Your loan amount may differ.
ANNUAL
TOTAL FINANCE TOTAL OF
LOAN AMOUNT PERCENTAGE
CHARGE PAYMENTS
RATE (APR)
The total interest you will pay.
$500 35.99% $15.28* $515.28*
$3,000 35.99% $91.70* $3,091.70*
$7,000 35.99% $213.97* $7,213.97*
* Estimated amount assuming loan repaid in full within 31 days of electronic filing. Payments made earlier may
decrease the amount of interest owed and payments made later may increase the amount of interest owed.
Because of COVID-19 and the possibility of delays in your receipt of your tax refund, this period may be longer
and more interest may accrue before your Refund Advance Loan is repaid; however, in no event will interest
accrue after 120 days. The Total Finance Charge is the total interest charge you will pay; there are no additional
fees for this loan.
Note: If you are also applying for a Refund Anticipation Check/Refund Transfer (“RT”) from a third party bank (“Third Party Bank”),
see the separate RT Disclosure from Third Party Bank for a summary of non-RAL fees that will be deducted and paid from your refund
(such as the Tax Refund Account Handling Fee, State Tax Refund Handling Fee, Transmittal Fee and Tax Preparation Fee) if you are
approved for an RT.
No fees are charged if your Refund Application Loan application is not approved.
The Refund Anticipation Loan is an extension of credit and not your actual personal income tax
refund.
Electronic filing of your tax return is available without applying for a Refund Anticipation Loan.
If your tax refund is less than expected, you will be required to repay only the amount of the loan
that equals the amount of your tax refund. You also may file your tax refund electronically or by
mail and receive your refund from the Internal Revenue Service by mail or direct deposit to your
bank account without a Refund Anticipation Loan or loan fees.
If First Century approves your application for a Refund Anticipation Loan, the loan proceeds will,
based on your election in the application, be disbursed either (A) to your GO2Bank Debit Card
and you will receive your GO2Bank Debit Card account number within 48 hours after the IRS
acknowledges acceptance of your tax return; your GO2Bank Debit Card will be mailed to you
and you should receive your GO2Bank Debit Card in 5-10 business days; (B) by check on the
next business day after approval, which check can be picked up by you at your tax preparer’s
office; or (C) by direct deposit to your bank account.
313389348.6
If you are a resident of Tennessee, Virginia or Washington State you may rescind a Refund
Anticipation Loan, on or before the close of business on the next day of business, by either
returning the original check issued for the loan or providing the amount of the loan in cash to First
Century or to your tax preparer.
If you do not obtain a Refund Anticipation Loan, the IRS advises that an individual can expect to
receive a tax refund on the following schedule when the individual’s return is filed electronically
or by mail:
Filing Method Disbursement Method Estimated Availability of Funds*

ANGELA SHACKLEFORD
By Mail IRS Issued Check or IRS Direct Deposit 6 months or more
E-File IRS Issued Check 21 to 28 days
E-File IRS Direct Deposit Within 21 days
*The estimates shown above do not include any additional time that may be required for your bank to post the
refund to your account, or for mail delivery. The IRS does not guarantee that a person will be paid the full
amount of an anticipated tax refund and does not guarantee a specific date on which a refund will be deposited
directly into your bank account or mailed to you.
BY SIGNING BELOW, YOU ACKNOWLEDGE RECEIVING THIS IMPORTANT

INFORMATION BEFORE YOU SIGNED THE FIRST CENTURY TAX REFUND
ADVANCE LOAN APPLICATION AND THE FIRST CENTURY TAX REFUND ADVANCE
LOAN AGREEMENT.
Taxpayer Signature: _______________________________________________________ Date:________________
Joint Taxpayer Signature (if filing jointly): ______________________________________ Date:________________
313389348.6
Taxpayer’s Name BLAKE D WEBER Taxpayer’s Name
Social Security No. xxx-xx-0727 Social Security No.
REFUND TRANSFER FEE DISCLOSURE

In this Refund Transfer (“RT”) fee disclosure form, the term “you”, “your” and “yours” refers to each “Taxpayer” signing below. The words
“we”, “us” and “our” refer to Santa Barbara Tax Products Group, LLC, a division of Green Dot Corporation, a Delaware corporation (“Servicer”)
and Civista Bank (“Bank”). In accordance with your instructions in the Refund Transfer Application and Agreement (“Agreement”), upon
receipt of your tax refund from the Internal Revenue Service (“IRS”), Servicer will pay out your refund as indicated below:
Expected Federal Refund Amount1 $_______________

18,495.00
Authorized Deductions:
Refund Transfer (RT) Fee and Related Fees:
1. RT Processing Fee2 $_______________

39.95
2. Other processing fee $_______________

0.00
Fees Related to Tax Preparation and/or Other Services or Products:
3. Amount paid to tax preparer for tax preparation services $_______________

2,800.00
4. Document preparation fee paid to tax preparer $_______________

0.00
5. Transmission fee paid to Transmitter3 $_______________

44.00
6. Check administration fee (if applicable)4 $_______________

0.00
7. Service bureau fee $_______________

55.00
8. Fees for additional services or products $_______________

0.00
Subtotal ($______________)
2,938.95
Amount paid directly to you5 $_______________

15,556.05
If you apply for and receive one or more tax refund advances from a third party refund advance provider in 2023, the above amount paid
directly to you will be reduced by the amount of such refund advances and accrued interest on those refund advances.
1 This Refund Transfer Fee Disclosure reflects the amount paid directly to you using the expected federal refund amount and does not
take into account any amount due to you from any state taxing authorities, as that amount is typically not estimable at this time. In the
event any of your state tax refunds are disbursed to Bank before the federal tax refund, the above fees will be deducted from that state
refund first, and any balance from subsequent refunds received. See the Subsequent Refunds section below for more details.
2
The RT Processing Fee will be retained by Servicer for its refund transfer processing services and may be shared with the transmitter of
your return to the IRS (“Transmitter”). Servicer shall pay Bank for its banking services. The RT Processing Fee will be increased by $14.95
if Servicer processes federal and state refunds for you (and an additional $14.95 fee will be incurred for each state thereafter if multiple
state returns are processed).
3 The transmission fee paid to Transmitter may include a technology fee and an electronic filing fee. A portion of the transmission fee paid
to Transmitter may be subsequently paid to the tax preparer.

4 You may be charged a $12.00 check administration fee for a cashier’s check disbursement option. This fee applies to disbursements of
both federal and state tax refunds and applies to each cashier’s check printed. The Servicer, Transmitter and tax preparer will each receive
a portion of the check administration fee. Inquire with your tax preparer to determine applicability of this fee.
5 The amount paid directly to you may be less if the IRS does not send us your full refund. If the amount actually paid to you is less than
the amount shown above, you can view an updated itemization on our website by logging on to www.sbtpg.com. As discussed in Footnote
1, the amount shown here does not reflect state tax refund amounts, if any.
Subsequent refunds: Although you may be filing for and receive tax refunds from both the IRS and one or more state tax authorities, the
itemization above only reflects your expected federal tax refund amount, as any refund due from a state taxing authority is typically not
estimable at this time. We will deduct the RT Processing Fee and the fees indicated above from the first tax refund the Bank receives,
whether that be federal or state, and any balance that remains unpaid will be deducted from any subsequent refunds in the order they
2023 RT Fee Disclosure_CAF, 2023-1A, January 2023

are received before disbursing any balance of the refund proceeds to you. Note that we will deduct the additional $14.95 RT Processing
Fee at the time the Bank receives any subsequent refund.
ADDITIONAL DISCLOSURES: Once your Agreement has been signed and transmitted to Servicer, and Servicer has received an
acknowledgement that your electronically filed tax return has been received and accepted by the IRS, a temporary deposit account (the
“Account”) will be opened in your name at Bank for the purpose of receiving a direct deposit of your tax refund from the IRS or state tax
authority. If and when the tax refund has been deposited by the IRS or state tax authority to your Account, Servicer will make all deductions
in the manner indicated above and disburse the balance of the Account to you in accordance with the disbursement method chosen by you
in the Agreement. Servicer and Bank have no control over and cannot guarantee if or when the IRS or state tax authority will issue you a
refund or what the amount of your expected tax refund will be. In the event your 2022 federal and/or state refunds are not sufficient to
cover the fees or other amounts due for products or services set forth in the Agreement, including repayment of and interest associated with
refund advance products (“Outstanding Amounts”), any Outstanding Amounts may be deducted from refunds that you may receive up to 24
months after the date of the Agreement and process through the Servicer.
If you select the direct deposit disbursement method, you authorize Servicer to electronically debit your personal bank account for tax
preparation, document preparation and electronic filing fees (“Tax Prep Fees”) in the event i) your Tax Prep Fees are not fully paid from
your federal and/or state refunds for any reason or if we consider, in our sole discretion, your refund proceeds delayed based on
applicable tax deadlines set by the IRS, and ii) your tax preparer has not opted out of the Auto-Collect Program (as defined in the
Agreement) or has not opted you, specifically, out of the Auto-Collect Program. For more details on the Auto-Collect Program and
instructions to opt out, please refer to section 5 of the Agreement. Note that any Outstanding Amounts not collected pursuant to the
Auto-Collect Program may still be recovered pursuant to the “Additional Disclosures” section above.
BY SIGNING BELOW, you acknowledge that you have received this Refund Transfer Fee Disclosure and agree to have your tax refunds
disbursed as indicated above.
Taxpayer Date Taxpayer (if filing jointly) Date
2023 RT Fee Disclosure_CAF, 2023-1A, January 2023

Consent to Use of Tax Return Information
ANGELA SHACKLEFORD
_______________________________________ (“we”, “us” and “our”)
Printed name of tax preparer
Federal law requires this consent form be provided to you (“you” refers to each taxpayer, if
more than one). Unless authorized by law, we cannot use your tax return information for
purposes other than the preparation and filing of your tax return without your consent.
You are not required to complete this form to engage our tax return 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. 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.
For your convenience, we have entered into an arrangement with Santa Barbara Tax Products
Group, LLC, a division of Green Dot Corporation, a Delaware corporation (“Processor”), using
banking services of Civista Bank, to provide qualifying taxpayers with the opportunity to apply
for refund processing services offered by and through Processor. To determine whether these
services may be available to you, we will need to use your tax return information by analyzing it
and calculating the amount of your anticipated refund.
If you would like us to use your tax return information to determine whether these services
may be available to you while we are preparing your return, please sign and date this consent
to the use of your tax return information.
By signing below, you (including each of you if there is more than one taxpayer) authorize us to
use the information you provide to us during the preparation of your 2022 tax return to
determine whether to present you with the opportunity to apply for refund processing services
through Processor.
BLAKE D WEBER
Printed Name of Taxpayer: ___________________________________
Taxpayer Signature: ____________________________________ Date: ____________
Printed Name of Joint Taxpayer: _______________________________

Joint Taxpayer Signature: ________________________________ Date: ___________
If you believe your tax return information has been disclosed or used improperly in a manner
unauthorized by law or without your permission, you may contact the Treasury Inspector
General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at
complaints@tigta.treas.gov.
2023 7216 Consent to Use, 2023-1A, January 2023

CONSENT TO USE OF TAX RETURN INFORMATION
For the purposes of this consent form, “we,” “us,” and “our” mean
_________________________
ANGELA SHACKLEFORD
(Printed name of Tax Preparer)
Federal law requires this consent form be provided to you (“you” refers to each taxpayer,
if more than one). Unless authorized by law, we cannot use your tax return information
for purposes other than the preparation and filing of your tax return without your consent.
You are not required to complete this form to engage in our tax return preparation services.
If we obtain your signature on this form by conditioning our tax preparation services on
your consent, your consent will not be valid. 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.
If you do not consent, you may still have your tax return prepared and electronically filed
by us for a fee.
For your convenience, we have entered into an arrangement with third parties to provide
qualifying taxpayers with the opportunity to apply for a Refund Advance Loan product
from First Century Bank, N.A. To determine whether this Refund Advance Loan product
may be available to you, we will need to use your tax return information in order to
calculate the amount of your anticipated refund.
If you would like us to use your tax return information to determine whether this Refund
Advance Loan product may be available to you while we are preparing your return, please
sign and date this consent to the use of your tax return information.
By signing below, you authorize us to use the information you provide to us during the
preparation of your 2022 tax return to determine whether to present you with the
opportunity to apply for this Refund Advance Loan product.
Printed name of taxpayer: BLAKE

_________________________________________________
D WEBER
Taxpayer signature: _______________________________ Date: _________________
Printed name of joint taxpayer: _____________________________________________
Joint taxpayer signature: ___________________________ Date: _________________
If you believe your tax return information has been disclosed or used improperly in a
manner unauthorized by law or without your permission, you may contact the Treasury
Inspector General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by
submitting a form on TIGTA’s website, www.tigta.gov.
313389316.2
Consent to Disclosure of Tax Return Information
___________________________________________________
ANGELA SHACKLEFORD (“we”, “us” and “our”)
Printed name of tax preparer
Federal law requires this consent form be provided to you (“you” refers to each taxpayer, if
more than one). Unless authorized by law, we cannot disclose your tax return information to
third parties for purposes other than the preparation and filing 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 return 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.
You have indicated that you are interested in applying for a Refund Transfer (“RT”) product
from Santa Barbara Tax Products Group, LLC, a division of Green Dot Corporation, a Delaware
corporation (“Processor”) using banking services of Civista Bank (“Bank”). In order to have your
refund processed by and through Processor, we must disclose all of your 2022 tax return
information to Processor and Bank.
If you would like us to disclose your 2022 tax return information to Processor and Bank for this
purpose, please sign and date your consent to the disclosure of your tax return information.
By signing below, you (including each of you if there is more than one taxpayer) authorize us to
disclose to Processor and Bank all of your 2022 tax return information so that Processor can
evaluate and process your application and Bank can provide banking services for the RT
product. You understand that if you are not willing to authorize us to share your tax
information with Processor and Bank, you will not be able to obtain an RT product from
Processor, but you can still choose to pay us directly to have your tax return prepared and filed.
Printed Name of Taxpayer: ___________________________________

BLAKE D WEBER
Taxpayer Signature: ____________________________________ Date: ____________
Printed Name of Joint Taxpayer: _______________________________

Joint Taxpayer Signature: ________________________________ Date: ____________
unauthorized by law or without your permission, you may contact the Treasury Inspector
General for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by email at
complaints@tigta.treas.gov.
2023 7216 Consent to Disclose, 2023-1A, January 2023

CONSENT TO DISCLOSURE OF TAX RETURN INFORMATION
For the purposes of this consent form, “we,” “us,” and “our” mean
_________________________
ANGELA SHACKLEFORD
(Printed name of Tax Preparer)
Federal law requires this consent form be provided to you (“you” refers to each taxpayer, if more
than one). Unless authorized by law, we cannot disclose your tax return information to third
parties for purposes other than the preparation and filing 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 in our tax preparation services. If we obtain
your signature on this form by conditioning our 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.
You have indicated that you are interested in receiving a Refund Advance Loan product from
First Century Bank, N.A. (“Bank”). In order to provide you with the opportunity to apply for this
Refund Advance Loan product, we must disclose all of your 2022 tax return information
necessary for evaluating the request to Bank or its service provider, Green Dot Corporation. If
you request a more limited disclosure of tax return information, you will not be eligible to submit
an application request for this Refund Advance Loan product. If you would like us to disclose
your 2022 tax return information to Bank for this purpose, please sign and date your consent to
the disclosure of your tax return information to Bank.
By signing below, you authorize us to disclose to Bank all of your 2022 tax return information
necessary for the evaluation and processing of your request for a Refund Advance Loan product.
You understand that if you are unwilling to authorize the disclosure and sharing of your tax return
information with Bank, you will not be able to obtain a Refund Advance Loan product from Bank,
but you may still choose to have your tax return prepared and filed by us for a fee.
Printed name of taxpayer: ______________________________________________________

BLAKE D WEBER
Taxpayer signature: ___________________________________ Date: ________________
Printed name of joint taxpayer: __________________________________________________
Joint taxpayer signature: ________________________________ Date: ________________
unauthorized by law or without your permission, you may contact the Treasury Inspector General
for Tax Administration (TIGTA) by telephone at 1-800-366-4484, or by submitting a form on
TIGTA’s website, www.tigta.gov.
313389280.2
DO NOT ERO MUST RETAIN THIS FORM.
E
PLEAS DO NOT SUBMIT THIS FORM TO
MA
GEORGIA DEPARTMENT OF REVENUE
IL!
UNLESS REQUESTED TO DO SO.
IRS DCN OR SUBMISSION ID GA-8453
202
GEORGIAINDIVIDUALINCOMETAXDECLARATION FOR ELECTRONIC FILING

SUMMARY OF AGREEMENT BETWEEN TAXPAYER AND ERO OR PAID PREPARER
$PHQGHG5HWXUQ
First Name and Initial Last Name Social Security Number

If Joint Return, Spouse’s First Name and Initial Spouse’s Last Name Spouse’s Social Security Number
Home Address (number and street) Apt Number Daytime Telephone Number
3650 DOGWOOD DR 404-545-6279
City, Town or Post Office State Zip Code
POWDER SPRINGS GA 30127
PART I TAX RETURN INFORMATION
1. Federal Adjusted Gross Income (Form 500 , Line 8; Form 500EZ, Line 1) .................. 1. 19470
2. Georgia Taxable Income (Form 500 , Line 15c; Form 500EZ, Line 3) ......................... 2. 11370
3. Net Georgia Tax (Form 500 , Line 22; Form 500EZ, Line 6) ........................................ 3. 476
4..Balance Due (Form 500, Line 4; Form 500X, Line 37; Form 500EZ, Line 2) ................................. 4.
5..Refund (Form 500, Line 4; Form 500X, Line 38; Form 500EZ, Line 2) ............................................ 5. 53
PART II DECLARATION OF TAXPAYER(S)
Under penalties of perjury, I declare that the information I have provided to my Electronic Return Originator (ERO) and/or Online Service
Provider and/or Transmitter and the amounts shown in Part I agree with the amounts shown on the corresponding lines of
the electronic portion of my 202 Georgia Income Tax Return. I declare that I have examined my tax return, including
accompanying schedules and statements, and to the best of my knowledge and belief, my return is true, correct and complete. I
consent that the electronic portion of my return may be sent by my ERO/Online Service Provider/Transmitter.
SIGN 03/14/23
HERE TAXPAYER’S SIGNATURE Date SPOUSE’S SIGNATURE (if joint return, both must sign) Date
BLAKE D WEBER JAXWEBER8892@GMAIL.COM

PRINT NAME EMAIL ADDRESS
PART III DECLARATION OF ELECTRONIC RETURNS ORIGINATOR AND PAID PREPARER

I DECLARE THAT I HAVE REVIEWED THE ABOVE TAXPAYER’S RETURN AND THAT THE ENTRIES ON THE GA-8453 ARE COMPLETE
AND CORRECT TO THE BEST OF MY KNOWLEDGE.
ERO’s Signature _____________________________________________________________ Date ______________________

03/14/23
ERO’s
Firm’s Name _______________________________________________________________
ANGELA SHACKLEFORD x
Check also if paid preparer
Use
Only Address _______________________________________________________________
2600 POPLAR AVE FEIN/PTIN P03031941
City, State, & Zip Code_________________________________________________________
MEMPHIS TN 38112 SSN/TIN
IF PREPARED BYANY PERSON OTHER THAN THE TAXPAYER, THIS DECLARATION IS BASED ON ALL INFORMATION OF WHICH
THE PREPARER HAS ANY KNOWLEDGE.
Paid Preparer’s Signature _____________________________________________________ Date ______________________

Paid
Firm’s Name _______________________________________________________________ FID/TIN
Preparer’s
Use Only Address _______________________________________________________________ SSN/TIN
City, State, & Zip Code_________________________________________________________
GA-8453 (REV //)
KEEP A COPY WITH YOUR RECORDS
1038
2300403814
Georgia Form 500(Rev. 06/22/22)

Individual Income Tax Return
Georgia Department of Revenue
2022 (Approved software version)
Page 1
Fiscal Year
Beginning STATE GA
ISSUED
rsion) YOUR DRIVER’S

Fiscal Year
LICENSE/STATE ID
Ending 051469213
YOUR FIRST NAME MI YOUR SOCIAL SECURITY NUMBER

1. BLAKE D 259-77-0727
LAST NAME (For Name Change See IT-511 Tax Booklet) SUFFIX
WEBER
SPOUSE’S FIRST NAME MI SPOUSE’S SOCIAL SECURITY NUMBER
DEPARTMENT USE ONLY
LAST NAME SUFFIX
ADDRESS (NUMBER AND STREET or P.O. BOX) (Use 2nd address line for Apt, Suite or Building Number) CHECK IF ADDRESS HAS CHANGED
2. 3650 DOGWOOD DR
CITY (Please insert a space if the city has multiple names) STATE ZIP CODE
3. POWDER SPRINGS GA 30127
(COUNTRY IF FOREIGN)
Residency Status
4. Enter your Residency Status with the appropriate number ....
...................................................................................................... 4. 1
1. FULL- YEAR RESIDENT 2. PART- YEAR RESIDENT TO 3. NONRESIDENT
Omit Lines 9 thru 14 and use Form 500 Schedule 3 if you are a part-year or nonresident filer.
Filing Status
5. Enter Filing Status with appropriate letter (See I T - 5 1 1 Tax Booklet)...................................................................................
.... .... 5. A
A. Single B. Married filing joint C. Married filing separate (Spouse’s social security number must be entered above) D. Head of Household or Qualifying Surviving Spouse
6. Number of exemptions (Check appropriate box(es) and enter total in 6c.) 6a. Yourself X 6b. Spouse 6c. 1
7a. Number of Dependents (Enter details on Line 7b., and DO NOT include yourself or your spouse)...................................... 7a.
This Page (1) is required for processing

Georgia Form 500
Georgia Department of Revenue 2300403824 YOUR SOCIAL SECURITY NUMBER
2022 259-77-0727
Pag e 2
7b. Dependents (If you have more than 4 dependents, attach a list of additional dependents)
First Name, MI. Last Name
Social Security Number Relationship to You
INCOME COMPUTATIONS
If amount on line 8, 9, 10, 13 or 15 is negative, use the minus sign (-). Example -3456.
8. Federal adjusted gross income (From Federal Form 1040)..................................... 8. 19470

(Do not use FEDERAL TAXABLE INCOME) If the amount on Line 8 is $40,000 or more, or your gross income is less than your
W-2s you must include a copy of your Federal Form 1040 Pages 1, 2, and Schedule 1.
9. Adjustments from Form 500 Schedule 1 (See IT-511 Tax Booklet) ....................... 9.
10. Georgia adjusted gross income (Net total of Line 8 and Line 9)............................. 10. 19470
11. Standard Deduction (Do not use FEDERAL STANDARD DEDUCTION).............. 11a. 5400
(See IT-511 Tax Booklet)
b. Self: 65 or over? Blind? Total x 1,300=......................... 11b.

Spouse: 65 or over? Blind?
c. Total Standard Deduction (Line 11a + Line 11b)................................................... 11c. 5400
Use EITHER Line 11c OR Line 12c (Do not write on both lines)
12. Total Itemized Deductions used in computing Federal Taxable Income. If you use itemized deductions, you must include Federal Schedule A.
a. Federal Itemized Deductions (Schedule A- Form 1040)............................... 12a.
b. Less adjustments: (See IT-511 Tax Booklet) ................................................ 12b.
c. Georgia Total Itemized Deductions.................................................................. 12c.
13. Subtract either Line 11c or Line 12c from Line 10; enter balance.......................... 13. 14070
Georgia Form 500
2022 259-77-0727
Pag e 3
14a. Enter the number from Line 6c. 1 Multiply by $2,700 for filing status A or D 14a. 2700
or multiply by $3,700 for filing status B or C
14b. Enter the number from Line 7a. Multiply by $3,000.......................................... 14b.
14c. Add Lines 14a. and 14b. Enter total ...................................................... 14c. 2700
15a. Income before GA NOL (Line 13 less Line 14c or Schedule 3, Line 14)..... 15a. 11370
15b. Georgia NOL utilized (Cannot exceed Line 15a or the amount after
applying the 80% limitation, see IT-511 Tax Booklet for more information)....15b.
15c. Georgia Taxable Income (Line 15a less Line 15b)..................................... 15c. 11370
16. Tax (Use Tax Rate Schedule in the IT-511 Tax Booklet) .......................... 16. 481
17. Low Income Credit 17a. 1 17b. 5 ........................ 17c. 5

18. Other State(s) Tax Credit (Include a copy of the other state(s) return) ....... 18.
19. Credits used from IND-CR Summary Worksheet ........................................ 19.
20. Total Credits Used from Schedule 2 Georgia Tax Credits (must be filed 20.
electronically)
21. Total Credits Used (sum of Lines 17-20) cannot exceed Line 16 ............................. 21. 5
22. Balance (Line 16 less Line 21) if zero or less than zero, enter zero .......... 22. 476
INCOME STATEMENT DETAILS Only enter income on which Georgia tax was withheld. Enter income from W-2s, 1099s, and G2-As on Line 4
GA Wages/Income. For other income statements complete Line 4 using the income reported from Form G2-RP Line 12 or 13; Form G2-LP Line
11, or for Form G2-FL enter zero.
(INCOME STATEMENT A) (INCOME STATEMENT B) (INCOME STATEMENT C)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:

X W-2 G2-A G2-LP X W-2 G2-A G2-LP W-2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN)
X SSN ID NUMBER (FEIN)
X SSN ID NUMBER (FEIN) SSN
472769653 834494982
3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID

3193362YQ 1902950001
4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME

9496 6480
5. GA TAX WITHHELD 5.. GA TAX WITHHELD 5. GA TAX WITHHELD

329 200
PLEASE COMPLETE INCOME STATEMENT DETAILS ON PAGE 4.

TAXSLAYER 01 1038-038 2022 GA 004 T1 22
Georgia Form 500
2022 259-77-0727
Page 4
(INCOME STATEMENT D) (INCOME STATEMENT E) (INCOME STATEMENT F)
1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE: 1. WITHHOLDING TYPE:
W-2 G2-A G2-LP W-2 G2-A G2-LP W-2 G2-A G2-LP
1099 G2-FL G2-RP 1099 G2-FL G2-RP 1099 G2-FL G2-RP
2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL 2. EMPLOYER/PAYER FEDERAL
ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN ID NUMBER (FEIN) SSN
3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID 3. EMPLOYER/PAYER STATE WITHHOLDING ID
4. GA WAGES / INCOME 4. GA WAGES / INCOME 4. GA WAGES / INCOME
5. GA TAX WITHHELD 5. GA TAX WITHHELD 5. GA TAX WITHHELD
23. Georgia Income Tax Withheld on Wages and 1099s ............................. 23. 529
(Enter Tax Withheld Only and include W-2s and/or 1099s)
24. Other Georgia Income Tax Withheld ........................................................ 24.
(Must include G2-A, G2-FL, G2-LP and/or G2-RP)
25. Estimated Tax paid for 2022 and Form IT-560 ......................................... 25.
26. Schedule 2B Refundable Tax Credits.......................................................... 26.

(Cannot be claimed unless filed electronically)
27. Total prepayment credits (Add Lines 23, 24, 25 and 26)........................... 27. 529
28. If Line 22 exceeds Line 27, subtract Line 27 from Line 22 and enter
balance due............................................................................................... 28.
29. If Line 27 exceeds Line 22, subtract Line 22 from Line 27 and enter
overpayment .............................................................................................. 29. 53
30. Amount to be credited to 2023 ESTIMATED TAX ................................. 30.
31. Georgia Wildlife Conservation Fund (No gift of less than $1.00)............. 31.
32. Georgia Fund for Children and Elderly (No gift of less than $1.00)........ 32.
33. Georgia Cancer Research Fund (No gift of less than $1.00) ................. 33.
34. Georgia Land Conservation Program (No gift of less than $1.00)........... 34.
35. Georgia National Guard Foundation (No gift of less than $1.00) ............. 35.
36. Dog & Cat Sterilization Fund (No gift of less than $1.00) ....................... 36.
37. Saving the Cure Fund (No gift of less than $1.00)................................. 37.
38. Realizing Educational Achievement Can Happen (REACH) Program ............. 38.
(No gift of less than $1.00)
Georgia Form 500
2022 259-77-0727
Pag e 5
39. Public Safety Memorial Grant (No gift of less than $1.00)....................... 39.
40. Form 500 UET (Estimated tax penalty) 500 UET exception attached 40.
41. Penalty: Late Payment and/or Late Filing.................................................... 41.
42. Interest ........................................................................................................ 42.
43. (If you owe) Add Lines 28, 31 thru 42 .................................................... 43.
MAKE CHECK PAYABLE TO GEORGIA DEPARTMENT OF REVENUE,
Mail To: GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER,
PO BOX 740399 ATLANTA, GA 30374-0399
44. (If you are due a refund) Subtract the sum of Lines 30 thru 42 from Line 29
THIS IS YOUR REFUND......................................................................... 44. 53
Refund Due Mail To: GEORGIA DEPARTMENT OF REVENUE PROCESSING CENTER,
PO BOX 740380 ATLANTA, GA 30374-0380
If you do not enter Direct Deposit information or if you are a first time filer you will be issued a paper check.
44a. Direct Deposit (U.S. Accounts Only) Type: Checking X Savings
Routing Account
Number 125109019 Number 875103673534
Mail pages 1-5 and any applicable schedules, forms, and documentation. DO NOT staple pages.
I/We declare under the penalties of perjury that I/we have examined this return (including accompanying schedules and statements) and to the best of my/our knowledge
and belief, it is true, correct, and complete. If prepared by a person other than the taxpayer(s), this declaration is based on all information of which the preparer has knowledge.
Taxpayer’s Signature (Check box if deceased) Spouse’s Signature (Check box if deceased)
Taxpayer’s Date of Death Spouse’s Date of Death
Taxpayer’s Signature Date Taxpayer’s Phone Number Spouse’s Signature Date

03/14/2023 404-545-6279
By providing my e-mail address I am authorizing the Georgia Department of Revenue to electronically notify me at the below e-ma il address regarding any updates to
my account(s).
Taxpayer’s E-mail Address X
JAXWEBER8892@GMAIL.COM I authorize DOR to discuss this return
with the named preparer.
Preparer’s Phone Number

901-247-4674
Signature of Preparer
Name of Preparer Other Than Taxpayer Preparer’s FEIN
ALEXIS BEAN 84-3927262
Preparer’s Firm Name Preparer’s SSN/PTIN/SIDN

ANGELA SHACKLEFORD P03031941

BLAKE D. WEBER 259-77-0727
LOW INCOME CREDIT WORKSHEET
the close of the tax year for which the credit may be claimed.
(QWHUWKHDPRXQWIURP)RUP/LQHRU)RUP(=/LQH 19470
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1
1RWH)RUSXUSRVHVRIWKHORZLQFRPHFUHGLW GHSHQGHQWVGRQRWLQFOXGHWKRVHXQERUQZLWKDGHWHFWDEOH
KXPDQ KHDUWEHDW
(QWHULI\RXRU\RXUVSRXVHLVRUROGHUHQWHULI\RXDQG\RXUVSRXVHDUHRUROGHU
1
)LQGWKHFUHGLWWKDWFRUUHVSRQGVWR\RXULQFRPHLQWKHWDEOHEHORZDQGHQWHURQOLQHERI)RUP
5

5
&UHGLW7DEOH )HGHUDO$GMXVWHG*URVV,QFRPH &UHGLW

8QGHU
EXWQRWPRUHWKDQ
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Invoice: Angela Shackleford 2600 Poplar Ave Memphis TN 38112 (901) 247-4674

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Invoice: Angela Shackleford 2600 Poplar Ave Memphis TN 38112 (901) 247-4674

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ANGELA SHACKLEFORD

2600 POPLAR AVE

CLIENT : 259-77-0727 BLAKE D WEBER BIRTH DATE : 11/16/1988 Age:34

ADDRESS : 3650 DOGWOOD DR PREPARER : 995

Home : (404) 545-6279 PREPARER FEE : 2,800.00

PREPARER : 995 DATE : 03/14/2023

TOTALS...... 15976 1456 991 232 529

d Control number 9 10 Dependent care benefits

13 Statutory Retirement Third-party 12b

f Employee’s address and ZIP code

GA 3193362YQ 9496 329

Form W-2 Wage and Tax Statement

259-77-0727 OMB No. 1545-0008

d Control number 9 10 Dependent care benefits

13 Statutory Retirement Third-party 12b

f Employee’s address and ZIP code

GA 1902950001 6480 200

I authorize ANGELA SHACKLEFORD:

Discretion-the freedom to decide what should be done in a particular

Taxpayer PIN: 10727

PIN Date 3/15/2023

Signature: ______________________________________________ Date: _______________

Tax Payer Due Diligence - 1 of 1

BLAKE D WEBER 259-77-0727

Spouse’s PIN: check one box only

Spouse’s signature a Date a

ERO’s signature a 03/14/2023 Date a

Phone no. (404) 545-6279 Email address Jaxweber8892@gmail.com

Part II Adjustments to Income

Part II Other Taxes (continued)

Part II Other Payments and Refundable Credits

36 Purchases less cost of items withdrawn for personal use . . . . . . . . . . . . . . 36

37 Cost of labor. Do not include any amounts paid to yourself . . . . . . . . . . . . . . 37

38 Materials and supplies . . . . . . . . . . . . . . . . . . . . . . . . 38

40 Add lines 35 through 39 . . . . . . . . . . . . . . . . . . . . . . . . 40

41 Inventory at end of year . . . . . . . . . . . . . . . . . . . . . . . . 41

a Business b Commuting (see instructions) c Other

47a Do you have evidence to support your deduction? . . . . . . . . . . . . . . . . . . . . Yes No

b If “Yes,” is the evidence written? . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

CELL PHONE BILL 1563

FURTHER EDUCATION 1365

48 Total other expenses. Enter here and on line 27a . . . . . . . . . . . . . . . . 48 2928

BLAKE WEBER 259-77-0727

i BARBER SHOPS 88-4307277 3494

2 Total qualified business income or (loss). Combine lines 1i through 1v,

SANTA BARBARA TAX PRODUCTS GROUP, LLC

2023 RT Application and Agreement_CAF 2023-1B, January 2023

2023 RT Application and Agreement_CAF 2023-1B, January 2023

Questions? Call 800-901-6663

2023 RT Application and Agreement_CAF 2023-1B, January 2023

SANTA BARBARA TAX PRODUCTS GROUP, LLC

REFUND TRANSFER APPLICATION AND AGREEMENT

APPLICANT INFORMATION (Complete for both taxpayers if filing a joint return)

Taxpayer’s Name _______________________________

Social Security No. _______________________________

Taxpayer’s Cell Phone No. _________________________

2023 RT Application and Agreement_CAF 2023-1B, January 2023

2023 RT Application and Agreement_CAF 2023-1B, January 2023

2023 RT Application and Agreement_CAF 2023-1B, January 2023

Bank and Servicer agree to all the terms of this Agreement.

2023 RT Application and Agreement_CAF 2023-1B, January 2023

FACTS What does Civista Bank do with your Personal Information?

• Social Security number and account balances

Signature: ________________________________ Date: _

Taxpayer Signature: _______________________________________ Date:

Joint Taxpayer Signature (if filing jointly): ______________________ Date: