Parent Membership Pg 1

"Payment Protection" Services!

Paycare Program

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PayCare

Membership Agreement

MEMBERSHIP FEES

$125.00 Annually Per Parent, Per Child up to 12th Grade

(*No up-front, out-of-pocket $125.00 membership fee for parents)

CONSULTATION SERVICE

To consult on the customized “Paycare Promise” Plan required for parents to access Payment Protection

'Pay Incentives' for their child(ren) from birth through the 12th Grade; To Consult on financial stability & the processing and obtaining of 'Pay incentives'.

'Pay Incentives' can be over a 12-month membership period.

[PAGE 1] First & Last Name

Date of Birth * required

Your Address

Monthly Rent/Mortg Pmt

Rent or Own?

How Long at this Residence?

Apt#or Unit#

Am I Eligible For Membership?*

(*all boxes must be checked & true) * Required

I am a parent/caregiver (*Non-parents also allowed).

I have total household monthly income of $1920.00 or more (any source allowed).

My identity & All my information is verifiable.

I have a checking account (+ balance) at a brick-n-mortar bank/credit union OR Chime.

I have no judgments & no incarcerations

I have no bankruptcy & no tax liens

Membership Type(s) *

Plus (Childcare thru Grade 12 & Extra-curricular)

Home (Rent/Mortgage/Utilities/Repairs)

Scholar (Tuition/Textbook/etc. for College & Specialty Schools)

Medical (Doctor Visits & Co-Pays)

Auto (Repairs, Down payments & Past-due Payments)

Number of Children*

Phone Number*

Email Address*

State/State ID# Or Driver's License #

Expiration Date

Social Security Number *

SERVICE (*Check All):*

Upon joining, I am not required to pay my $125 Membership Fee, up front, and I have the benefit of my Payments being protected in the area(s) indicated above, in the "Membership Type" Section. Payment Protection means that my payments can, temporarily, be continued on my behalf as long as I meet Program Eligibility.

Upon joining, I must select and sign for the 'Consent To Receive Services' Agreement (*bottom of this page).

To initiate each 'Payment Protection' 'Pay Incentive' service, I must pay the $40.42 'Payment Protection' monthly service fee to Paycare Program..

To initiate each 'Payment Protection' 'Pay Incentive' service, I must pay the $30 Enrollment Fee, admin fee & 3% per-transaction Fee, and my bill amount. I can choose to have my down payment go towards the final payment on my 'Payment Protection' Plan; Relieving me of making the final payment.

I fully understand that, in the event that I need to use "Payment Protection", my bill amount will be direct deposited into my bank account.

I understand that I may choose to have multiple 'Payment Protection' Pay Incentives, simultaneously.

I understand that 'Payment Protection' is activated for me once I make my 1st two on-time payments of my bill, because this shows 'good-faith' that I intend to pay my bill(s) according to the program requirements.

For each 'Pay Incentive', I agree to make payments as agreed and within the terms as agreed. I understand that if it is suspected that I intend solely to meet the required 2 on-time payments, then have payments made for me, I will be ejected from the Program.

Upon signing a “Paycare Promise” form, I agree to make the payments as agreed. I understand that future payment requests for 'Payment Protection" is determined by my keeping my current 'Paycare Promise' in place, as agreed.

Within 24 to 48 hours, my 'Payment Protection' plan options will be sent to me by Paycare Program (when applicable).

I fully agree to, complete, and sign this Paycare membership agreement, provide all required documentation, and meet Paycare Program eligibility prior to receiving services.

I understand that my annual Membership Agreement renews automatically, on February 1st of each year.

OPTIONAL FEES: Any applicable fees can be put on Paycare Card and be 'rolled into' Pay Incentive (*Check All):

Never an up-front $125.00 annual membership fee per member, per child, per service; Paid at $40.42 per month

$10.00 “Paycare” Card renewal fee, annually

Option: $3.00 fee for any additional or lost “Paycare” Card

Option: Customized fee per “Paycare Promise” form; including Renewed Plans

Default 0% Interest on all 'Payment Protection' plans

Option: $100 Convenience Fee for each year beyond my 12-month membership

**Signatures** (Check All): *

This Membership Agreement shall cover a period of 1 year, to be automatically renewed, unless a written cancellation is received by either Party 30 days prior to the automatic renewal date. Any suspected or tracked abuse will result in revoked membership and forfeit of fees. If any provisions of this Agreement are breached, the Parties agree to Mediation services to settle any and all disputes.

By checking/completing the boxes below, I agree that the electronic digitized signature(s) I apply on the following documents are representations of my signature and are legally valid and binding as if I had signed the document with ink on paper in accordance with the Uniform Electronic Transactions Act (UETA) and the Electronic Signatures in Global and National Commerce Act (E-SIGN) of 2000.

Disclosure Acknowledgement*

By checking this box, I acknowledge I have reviewed & understand the "How It Works" Page on the Paycare website.

E-Signature Date*

E-Sign (Type Your Name)*

Click to Agree to/Confirm Services

Don't Forget to Complete Page 2!!

Click Here

Thank you for contacting us. We will get back to you in 24 to 48 business hours! Don't forget to go back & complete "Consent For Services" form.

Paycare Menu of Our 6 Main Services:

Paycare Home|Repairs|Non-Eviction

Mission:

To prevent finances from being an obstacle between families with children/youth and the most stable housing possible.

(Funds can be paid directly to Residential Leasing facilities on behalf of families; And the new Non-Eviction Leases!)

Paycare's New 'How We Care' Shows

Mission:

To prevent finances from being an obstacle between children and their best

possible life outcomes.

(Parents enjoy monthly audio and/or video Segments focusing on family, children,

and how our Services support both!)

Paycare Plus

Mission:

To prevent finances from being an obstacle between children/youth, from birth to Grade 12, and the best

extra-curricular/education possible.

(Funds can be paid directly to Childcare & extra-curricular facilities, up to the child's

12th grade year!)

Paycare Scholar

Mission:

To prevent finances from being an obstacle between children/youth and the best college education possible.

(Funds can be paid directly to post-secondary education facilities on behalf of families!)

Paycare Medical

Mission:

To prevent finances from being an obstacle between children/youth and the best healthcare possible.

(Funds can be paid directly to medical, clinical, and health facilities on behalf of families!)

Paycare Auto

Mission:

To prevent finances from being an obstacle between families with children/youth and dependable transportation.

(Funds can be paid directly to auto repair and sales dealerships on behalf of families!)

|Integrity |Execution |Vision

7-B Corporate Center Court

Greensboro, NC 27408

Ph#: 336.303.1208