Customer Number


Mother's Maiden Name

Your Email Address


(exactly how it appears on your checks)


(middle name/ initial if used)



To receive an extension of payment for the original cash advance plus fee, submit this form for the extension of payment fee only to be debited on your original due date.

Your next pay date. 


If you have any comments or if we need to update your file with new information please specify in the comment box below.

I authorize and request AmeriCash Advance LLC to debit the (extension of payment fee portion) by ACH/EFT and/or bank draft from my account on the original scheduled repayment date for my current and existing $400 cash advance.

I agree, that if I have not requested an additional amount to be applied to current balance on this form, I confirm and authorize that I still owe the original $400 advance amount plus fee (for a total amount of $500), to be debited in full from my account on the extended date shown above. I acknowledge and agree this extension of payment fee is $100.

*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 amount equal to the extension fee 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 ACH/EFT and/or bank drafts to AmeriCash Advance to occur in a timely manner for the scheduled due date. I further agree and confirm that by submitting completed/ signed americashadvance.com internet request forms as a matter of convenience, hereby constitutes the same legal and binding document as providing AmeriCash Advance LLC with my personal post dated check, in the amount of the cash advance plus associated fees. If the payment is returned for ANY reason, I agree that I will also pay a $25.00 return fee. I agree that upon submission of my electronic signature, I am not presently involved in, nor contemplating bankruptcy proceedings now or in the future.

I understand, acknowledge, and fully agree this transaction is made pursuant to my current outstanding promissory note/ loan document and is NOT an installment loan that I can make payments on, but is due in full on the extended due date above. Furthermore, it is 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)

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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