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Pay Incentive TYPE(S) *

Facility To Be Paid *

Facility Contact Name*

Facility Phone Number*

Acct# and Monthly Payment Amount*

2nd Facility To Be Paid

2nd Facility Contact Name

2nd Facility Phone #

Acct# and Monthly Payment Amount

3rd Facility To Be Paid

3rd Facility Contact Name

3rd Facility Phone #

Acct# and Monthly Payment Amount

4th Facility To Be Paid

4th Facility Contact Name

4th Facility Phone #

Acct# and Monthly Payment Amount

YOUR NAME (First, Middle, Last)

YOUR ADDRESS (Include Any Unit#, City, State, Zip) 

YOUR PHONE#

YOUR EMAIL ADDRESS 

Child#1 Name & Date of Birth

Child#2 Name & Date of Birth

Child#3 Name & Date of Birth

Child#4 Name & Date of Birth

My Credit Ranges from....*

For Processing, I understand I am to also submit 5 documents by Uploading below or by EMAIL: membership@paycareprogram.org (check all boxes): *

Upload 1st File
Upload supported file (Max 15MB)
Upload 3rd File
Upload supported file (Max 15MB)
Upload 2nd File
Upload supported file (Max 15MB)
Upload 4th File
Upload supported file (Max 15MB)
Upload 5th File
Upload supported file (Max 15MB)

Employer Name*

Employer's Full Address *

City *

 State *

Zipcode *

Employer Phone# *

Time in Position *

Position Held *

Salary/Payrate Amount*

Pay Frequency*

Time at Previous Job

                                             ***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 Members need additional assistance with  or Medical, transportation, Tuition payments  or with

 Lease payments, know that Paycare is here!!

Simply complete our

PAY INCENTIVES ENROLLMENT FORM

to receive a 'Payment Protection'

services. You can begin your

12-month membership to have payments  continued for your family!

&

 refer us to help as many families as possible!

*************************

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.

Paycare Menu of Our 6 Main Services (*Click below):

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 paid directly to Residential Leasing facilities on behalf of families; Home Repairs from USDA; And Non-Eviction Leases!)

Paycare 'Fresh Start' Credit Builder

Mission:

To prevent finances from being an obstacle between families with children, of even the most modest circumstances, and access to the best life outcomes possible.  

(Parents enjoy total control of their credit success story by choosing # of approvals and amount to be placed in savings!)  

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 paid directly to Childcare & extra-curricular facilities, up to child's 12th grade!)

Paycare Scholar

Mission:

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

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

​

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