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Personal

Payroll Advance Form


* indicates a required field


Personal Information:

Membership Number
(Must be Member to apply.)
Name (First M. Last)
Social Security Number/Taxpayer ID
Date of Birth //
Mother's Maiden Name
Daytime Phone:
Email:

Eligibility:

You must answer yes to the questions below in order to qualify for Payroll Advance.
Is this your first time requesting a Payroll Advance? Yes No
Have you had 3 consecutive months of direct deposit or payroll deposit payments to your California Credit Union accounts in the previous 3 months? Yes
Is your next scheduled direct deposit or payroll deposit no more than 30 days from today's date? Yes
Date of your next scheduled direct deposit or payroll deduction: / /
You have no California Credit Union accounts or loans in collection? Yes
You have no outstanding Payroll Advances? Yes

Payroll Advance Amount:

$500 maximum in $100 increments - cannot exceed Direct Deposit/Payroll Deposit amount. Fee is deducted from the payroll Advance Amount.
(Example: If Payroll Deposit is $250, maximum Payroll Advance amount is $200)
$100($10 fee) $200($20 fee) $300($30 fee) $400($40 fee) $500($50 fee)
 

Disbursement Method:

Deposit to savings Deposit to checking
 

Agreement & Authorization:

I hereby request a Payroll Advance for the amount indicated above. In order to qualify for a Payroll Advance, I understand that I must be a member in good-standing and must be actively enrolled in a Direct Deposit or Payroll Deduction plan of which the next scheduled payment date is no more than 30 days in the future. I understand that only one Payroll Advance is permitted per membership each Direct Deposit or Payroll Deduction cycle. I authorize you to deduct the amount of the Payroll Advance and any applicable fees from my savings or checking account on the next scheduled payment date of my Direct Deposit or Payroll Deduction (or ACH credit, if applicable). I understand that if I cancel or change my Direct Deposit or Payroll Deduction or such Direct Deposit or Payroll Deduction is not received by the California Credit Union for any reason, I will be liable for any outstanding Payroll Advance(s) nonetheless and will not be eligible for another Payroll Advance until all outstanding Payroll Advance(s) are paid in full. I understand and agree that the Payroll Advance service will be subject to the terms of this agreement, as well as to the Account Disclosure & Agreement.

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