Parent Promise Form

Paycare Program "Parent Promise" Form

(To Complete with Every "Pay Incentive " Request)

For long-term Consultative Services and to ensure that I meet my goal of continued access to "Pay Incentives" for my child(ren)'s best

educational (birth to 12th grade), college , medical, transportation, and housing experience.

[PAGE 3] Name

Type of Pay Incentive:*

(Select All That Apply To Your Situation)

Residential: Non-Eviction Lease

Commercial: Non-Eviction Lease

Mortgage: USDA GRANT (Home Repairs)

Healthcare Fees

Childcare Up to 12th Grade & extra-curricular

College Fees

Car Payments

"Fresh Start" Credit (Re)Builder: (Up to 3 Guaranteed Approvals; Option for $250 - $500 in Savings)

Benevolence: (C'mmty Outeach/Church Budget & Pledges 'Pmt Protection'; Members' Pmt Protection')

Your Email Address*

Number of Children*

Amount Requested:*

I Agree That I Understand The Following:*

Statement of Agreement: *

I have read and agree to all the above, including fees which are intended to be continued for me; I agree to pay the agreed payments over my 12 month membership period (or other selected time frame below) via account draft to fulfill my current obligation for my family/child(ren). I fully understand meeting my obligations determine my repeat access to 'Pay Incentives'.

I Choose a Longer term than my 12-month Membership Period:

(Periods beyond the 1-yr membership will result in a $100 Convenience Fee per additional year.)

24 months

36 months

48 months

"Fresh Start" Credit (Re)Builder Options:

Builder (*Builds credit when you have no credit history)

Rebuilder (*Builds your credit history when it needs a 'Reset')

I do not choose "Fresh Start" Credit Builder at this time

E-Signature Disclosure*

(Check to agree to E-Sign this form.)

By checking this box, I agree that the electronic digitized signatures I apply on the following document 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.

*I have read and agree to the terms and conditions of the Responsibility, Privacy and Cancellation/Refund Policies shown under the 'About Us' Tab.

E-Signature*

(Please E-sign Your Full Name)

Signature Date *

Click to Agree To Receive Services

Thank you! Your message was sent successfully and we will contact you in 24 to 48 business hours. Don't forget to complete links #1 and #2.

Welcome to Paycare Program!

Your "Parent Promise" form is the final step to begin processing your "Pay Incentive"! Once we receive this form, along with the other 2 forms and attachments, our office goes to work on behalf of your family! We do this by contacting who you want us to pay on your behalf and getting you processed!

You will hear from one of our

agents within 24-48 hours

via phone and/or email.

Phone#: 336.303.1208.