graphic generated by


Customer Number


Mother's Maiden Name

Your Email Address


(exactly how it appears on your checks)


(middle name/ initial if used)



In order to receive an extension of original payment, complete the form below for the extension fee of $20 to be debited on your original due date.

Your next scheduled direct deposit pay date. 


  I authorize an EFT/ACH debit by AmeriCash Advance LLC  in the amount of:


I authorize AmeriCash Advance LLC to withdraw $20.00 from my account on my original due date by EFT/ACH, as a fee for extension of payment of the original advance plus fee ($120) that will still be owed and due in full on the extended date shown above.

*I agree that if this is my 5th or more extension of payment request of my original advance, AmeriCash Advance is authorized by me to automatically debit an additional $20 to be applied towards my balance with each extension of payment request until the balance is paid in full.

I agree to maintain an adequate balance and keep my account(s) open to allow all payments to AmeriCash Advance by EFT/ACH to occur in a timely manner for the scheduled due date. If the payment is returned for ANY reason, I agree that I will also pay a $25.00 return fee.

I acknowledge all such transactions are made pursuant to the Master Cash Advance Agreement, which has been previously executed and is on file with AmeriCash Advance.

I understand and agree. (Please type your signature)

  (submit my information for processing)

  (this will delete information given)

Important: If you do not receive an e-mail of confirmation that your extension of payment request was received and processed, this will mean it was not received by us and your account is still scheduled to debit for the full balance due.




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