2. Enrollment Information
4. First Name*
5. Last Name*
7. Date of Birth*
   Date of Birth
9. Address*
11. City*
12. State*
13. Zip*
15. Home Phone*
16. Cell Phone
17. Work Phone
19. Email Address*
23. Emergency Contact
25. First Name*
26. Last Name*
28. Address*
30. City*
31. State*
32. Zip*
34. Home Phone*
35. Cell Phone
36. Work Phone
40. Additional Information
42. Did you use the City of Dayton VITA Program for your tax preparation this year?*

    1. Yes
    2. No
44. If yes to the question above, please specify which site you visited.*
    -- Select One --Beavercreek Senior CenterFairborn Senior CenterMiamisburg Community CenterNorthwest Branch LibraryPartners in HopeSt Paul United Methodist ChurchThe Job CenterTrotwood VitaXenia Greene County Library
46. Did you receive the Earned Income Tax Credit (EITC) this year?*

    1. Yes
    2. No
48. Do we have your permission to contact the VITA site to verify this information?*

    1. Yes
    2. No
50. Would you be able to open an account with either Fifth Third Bank or First Financial Bank?*

    1. Yes
    2. No
52. Are there any past issues with these institutions that might prevent you from opening an account?*

    1. Yes
    2. No
54. As a resident of the City of Dayton, I declare that I used the VITA program for my 2025 taxes and received the Earned Income Tax Credit. To stay eligible for the $1,500 incentive, I agree that I must open an account with the designated bank and verify that I have no prior banking history that would prevent me from doing so. I also understand that I must attend four mandatory classes. I acknowledge that I will not receive the incentive if I fail to meet all of these requirements.*

    1. Agree
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field