Quick-Start Premium Kit Order Form

United Refund Services
PO Box 496378
Port Charlotte, Florida 33949-6378

I have enclosed my $25.00 payment in the form of a:

Personal Check ___ Money Order ___

Cashier's Check ___

Please send my Quick-Start Premium Kit to the following e-mail address:


Please include the following two state listings with my kit:

State Listing #1 ________________________________

State Listing #2 ________________________________

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