|NOTICE: All 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.
|Current Loan Amount:
Additional Amount to be Debited and Applied to Loan
|To receive an extension
of payment for the original line of credit,
submit this form for the extension of payment fee
only to be debited on your original due date.
Next Payment Date:
|Enter ANY Information Changes and/or
comments in the box below:
(such as changes in employment, address, phone numbers,
I authorize and request
National Cash Lenders to debit my payment by ACH/EFT and/or bank draft
from my account on the original scheduled or newley requested repayment
date for my current and existing line of credit.
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 line of credit payment and it will be debited
in full from my account on the requested date shown
*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
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 If the payment is returned
for ANY reason, I agree that I will also pay a $30.00
return fee, or fee allowable in my state of residence. 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 line of credit loan document.
Furthermore, it is pursuant to the Master
Line of Credit Agreement, which has been previously
executed and is on file with National Cash Lenders.
Cash Lenders, LLC. does not service any U.S. Armed
Forces members or it's dependents. By
signing I certify that I nor any of my dependents
are in any of the U.S. Armed Forces.
| I understand and
type your signature)
| For your records, please
a copy of your completed application before submitting.
If you do not receive an e-mail of confirmation
that your 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.
If you are in need
of help with credit counseling, please refer to
the National Foundation for Credit Counseling located