ACH FORM
Customer Bank Information
Depository Name:
Branch Location:
City:
State:
Zip Code:
Routing Number:
Re-enter Routing
Number:
Account Number:
Re-enter Account
Number:
Password:
This authorization is to remain in full force and effect until COMPANY
has received written notification from me (or either of us) of its
termination in such time and in such manner as to afford COMPANY
and DEPOSITORY a reasonable opportunity to act on it.
Customer Information
Customer Name:
ID Number:
Today's Date:
Password:
Payment Amount to
be Debited:
Date to be Debited:
AUTHORIZATION AGREEMENT FOR DIRECT PAYMENTS  
(ACH DEBITS)

Company Name:
V-Max, Inc. dba American Cash Advance / Cash Advance, Inc. / A-1 Cash
Loans, Inc. / Fast Cash of Illinois, Inc.

I (we) hereby authorize V-Max, Inc. dba American Cash Advance / Cash
Advance, Inc./A-1 Cash Loans, Inc./Fast Cash of Illinois, Inc. hereinafter
called COMPANY, to initiate debit entries to my (our)  Checking Account or
Savings Account (select one) indicated below at the depository financial
institution named below, hereinafter called DEPOSITORY, and to debit the
same to such account. I (we) acknowledge that the origination of ACH
transactions to my (our) account must comply with the provisions of U.S.
Law. If any ACH transaction is dishonored by the Depository, a $25.00 fee
will be charged to my (our) account listed below.

If  you wish to pay in cash on or before your due date, you must call the
office in which your original loan was borrowed from, no less than 2 days
prior to your payment due date.

*NOTE: Passwords are used in lieu of signature. If you do not have your
password please contact store location in which your loan has been
received from.
If you have any questions regarding the use of this form, or how to fill it out,
please contact the store location in which your loan was received from.
You can also bring in this printable version of the ACH form.