Parent Promise Form

"Payment Protection" Services!

Paycare Program

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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)

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)

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 NO up-front membership fees for any Family. There are the up-front fees of: $30 'Payment 'monthly Premium, $30 enrollment + the family's normal payment due

ALL membership fees will be 'rolled into' my 'Pay Incentive' provided by Paycare

I understand that I can choose to pay my bill in 12 to 48 months

NEVER ANY INTEREST if I choose a term within my 12-mo membership period

I can have multiple 'Pay Incentives' at once

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 my 12- month membership term.

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.

Membership 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

Only after accepting services, will a 'hard' inquiry occur, to build my credit score [For Credit-Builder Program]

I may choose "Fresh Start" Credit (Re)Builder to build my Credit Score!

"Fresh Start": If I choose 3 Approvals, I also receive $250-$500 in a Savings Account, after the 6th installment

I fully understand that "Fresh Start" does not remove past information from my Credit Report

"Fresh Start": I agree to pay my service fee in 3-12 installments, with the up-front fee of $30 enrollment, 3% PerTrans Fee + the 1st installment

"Non-Eviction Lease" (Commercial & Residential): I agree to pay my rent as agreed during the lease-term, with the up-front fee of $30Residential/$50 Commercial 'Payment Protection' Premium, $30 1-time enrollment + the monthly pmt.

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 reimburse 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 reimbursements determine my repeat access to funds.

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

Choose Your level and # of Approvals :

Builder: I select 1 Credit Approval of (3) $100 pmts

Builder: I select 2 Credit Approvals of (3) $100 pmts

Builder: I select 1 Credit Approval of (6) $100 pmts

Builder: I select 2 Credit Approvals of (6) $100 pmts

Builder: I select 3 Credit Approvals of (6) $100 pmts + receive $250 savings after the 6th pmt

(Re)Builder: I select 1 Credit Approval of (6) $200 pmts

(Re)Builder: I select 2 Credit Approvals of (6) $200 pmts

(Re)Builder: I select 3 Credit Approvals of (6) $200 pmts + receive $500 savings after the 6th pmt

I choose a LARGER Approval amount of $3,600 over (12) $300 pmts

I choose a LARGER Approval amount of $6,000 over (12) $500 pmts

I choose a LARGER Approval amount of 12,000 over (12) $1,000 pmts

If I Choose 3 LARGER Approval Options, I also receive $1000 in Savings after the 12th pmt

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.

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

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; Home Repairs from USDA; And Non-Eviction Leases!)

Paycare 'Fresh Start' Credit Builder

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.

(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!)

|Integrity |Execution |Vision