Parent Promise Form

"Payment Protection" Services!

Paycare Program

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Paycare Pays Child/Family Fees For...
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- Parent Pay Incentives
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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)

Rent/Mortgage, Repairs & Utilities

Childcare Up to 12th Grade & extra-curricular

Healthcare Fees

College Fees

Car Repairs, Down Payments & Past-Due Payments

Your Email Address*

Number of Children*

Please Select The Number Of Children In Household

Amount Requested:*

I Agree That I Understand The Following:*

(Check all boxes below)

There are NEVER up-front membership fees for any Family

ALL membership fees come out of funds provided by Paycare

I understand that I reimburse my bill in 12 to 48 months.

I reimburse My 'Pay Incentive' for repeat access to $$$

My FREE Paycare Card renews annually for $10.00

Lost/Additional Paycare Cards cost $3.00 (*Optional)

$100/yr if I choose to go beyond 12 mos to reimburse funds

There is a 10% Convenience fee per "Pay Incentive"

There is a custom Parent Promise fee per 'Pay Incentive'

Funding is based on verification of all information I provide

My verification is done via a 'soft' credit inquiry so my credit will not be impacted

I have read & understand the Parent 'FAQs' page

There is an Origination fee (Paycare does not receive this fee)

Only after accepting funds, will a 'hard' inquiry occur, to build my credit score

I may receive more or less than the amount requested

If Full Amount Is Not Granted:*

(Select only the box which applies to your situation)

I Will Not Accept Funding (funds remain available 59 days)

I Will Accept Funding

Statement of Agreement: *

I have read and agree to all the above, including fees which are intended to be paid for me now: I agree to replenish the funded amount over my 12 month membership period (or other selected time frame below) via account draft to replenish my current obligation for my child(ren). I agree to any 'credits' for future requests. I fully understand my replenishments determine my ability to receive futur

I Choose Longer 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

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 *

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#: 336.897.3008.

Paycare Services:

Paycare Home

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!)

Paycare 'Starter'

Mission:

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

(Non-MemberReferring Facilities' funds are not paid directly to facilities, but paid directly to the families' accounts.)

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!)

[**Scroll up, slightly, to "Paycare Services" to select from 6 service(s) for your Facility!**]

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