| NOTICE: All
extension of payment requests must be submitted online
and must be received BY 11 A.M. EST the business day prior
to your scheduled full repayment due date to be changed
and processed. |
| Advance
Fee Status: |
|
Current
Advance Amount: |
|
| (Optional)
Additional Amount to be Debited and Applied to Loan Principle:
|
|
Anything over $500 please
specify in the comments section. |
| To receive
an extension of payment for the original cash advance
plus fee, submit this form for the extension of payment
fee only to be debited on your original due date. |
| Your
Extended Paycheck Date:
(mm/dd/yy) |
Enter ANY Information Changesand/or
comments in the box below:
(such as changes in employment,
address, phone numbers, bank info)
|
| I authorize
and request National Cash Lenders to debit the (extension
of payment fee portion) by ACH/EFT and/or bank draft
from my account on the original scheduled repayment
date for my current and existing cash advance.
I agree, that if I have not requested an additional
amount to be applied to current balance on this form,
I confirm and authorize that I still owe the original
advance amount plus fee, to be debited in full from
my account on the extended date shown above.
*I agree that if this is my 5th or more extension of
payment request of my original advance, National Cash
Lenders is authorized by me to automatically debit an
additional amount equal to the extension fee to be applied
towards my balance with each extension of payment request
until the balance is paid in full.
I agree to maintain an adequate
balance and keep my account(s) open to allow all ACH/EFT
and/or bank drafts to National Cash Lenders to occur
in a timely manner for the scheduled due date. I further
agree and confirm that by submitting completed/ signed
nationalcashlenders.com internet request forms as a
matter of convenience, hereby constitutes the same legal
and binding document as providing National Cash Lenders
with my personal post dated check, in the amount of
the cash advance plus associated fees. If the
payment is returned for ANY reason, I agree that I will
also pay a $30.00 return fee. I agree that upon submission
of my electronic signature, I am not presently involved
in, nor contemplating bankruptcy proceedings now or
in the future.
I understand, acknowledge, and fully
agree this transaction is made pursuant to my current
outstanding promissory note/ loan document and is NOT
an installment loan that I can make payments on, but
is due in full on the extended due date above. Furthermore,
it is pursuant to the Master Cash
Advance Agreement, which has been previously executed
and is on file with National Cash Lenders.
National
Cash Lenders, LLC. does not service any U.S. Armed Forces
members or it's dependants. By signing I
certify that I nor any of my dependants are in any of
the U.S. Armed Forces.
|
| I
understand and agree.
(Please type your signature) |
| For your
records, please print
a copy of your completed application before submitting.
|
| Notice:
If you do not receive an e-mail of confirmation that your
extension of payment request was received and processed,
this will mean it was not received by us and your account
is still scheduled to debit for the full balance due. |