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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:  
Social Security Number  
Mother's Maiden Name E-Mail
First Name Middle Name
Last Name  
(Optional) Additional Amount to be Debited and Applied to Loan Principal:           
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.
Your Next Payment Date: (mm/dd/yy)
Enter ANY Information Changes and/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 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 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 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.

National 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 agree.   (Please type your signature)
For your records, please print a copy of your completed application before submitting.
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Notice: 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 here

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