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Pay Incentive TYPE(S) *

*** SITUATION ***

Facility To Be Paid *

Facility Contact Name*

Facility Phone Number*

Amt Requested To Be Paid *

2nd Facility To Be Paid

2nd Facility Contact Name

2nd Facility Phone #

Amount Owed to 2nd Facility

Child#1 Name & Date of Birth

Child#2 Name & Date of Birth

Child#3 Name & Date of Birth

Child#4 Name & Date of Birth

****ABOUT YOU****

Your Name *

Your Telephone # *

Your Date of Birth [MM/DD/YYYY] *

Your Soc Sec # *

State ID/Drivers Lic# *

Issuing Date *

Your Address *

Apt# OR Unit#

City *

State*

Zip*

Years at Residence*

Your Email Address*

***FINANCIAL***

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My Credit Ranges from....*

Select the range that best reflects your situation

For Processing, I understand I am to also submit documents to EMAIL: membership@paycareprogram.org (check all boxes): *

***EMPLOYMENT***

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Employer Name*

Employer Phone# *

Employer Address *

Time in Position *

Position Held *

Salary/Payrate Amount*

Pay Frequency*

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* ***E-SIGNATURE SECTION***

By typing my name in the box below, I agree that the electronic digitized signature I apply on this document is representative 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.

E-Signature*

E-Signature Date*

Thank you for contacting us. A Professional Team Member will follow-up with you within 24 to 48 business hours! Don't forget to go back to complete link #3.

PAY INCENTIVES ENROLLMENT FORM

When Parents need assistance with Childcare or Medical, transportation, Tuition payments  or 

Tenants need assistance with Lease payments, know that Paycare is here!!

Simply complete our

PAY INCENTIVES ENROLLMENT FORM

to receive a 'Pay Incentive' for

assistance. You can replenish your 'Family Fund' over your 12-month membership! This allows you to access future funds for your family AND

to allow us to help as many families as possible!

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For the Purpose of determining the amount of Pay Incentives to be made on behalf of

your child, please complete the form on the left side of this screen.

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