1. Unless the authorization in item 4 below is properly and timely revoked, there will be a $15 fee on any ACH debit entry items that are returned at time of collection. You authorize AtmAdvance Corporation to contact you at your place of employmen or residence at any time up to 9:00 P.M. your local time, regarding your advance.

2.You represent that you have not recently filed for bankruptcy and have no present intentions of doing so.

3.You agree to pay the fee that was originally due on your advance at the time of your approved extension request. The original advance amount will extend to the due date of your next payroll entered below.

4. You authorize us, AtmAdvance Corporation of California, or our servicer or agent,to initiate one or more ACH debit entries(for example, at our option, one debit entry may be initaited for the principle of the advance and another for the finance charge) to your Deposit Account indicated in your AtmAdvance Corporation application for the single payment that comes due with regard to the advance for which you are applying. The Depository Institution named in your application on file, called BANK, will receive and debit such entries to your Checking Account. This Authorization becomes effective at the time we make you the for which you are applying and will remain in full force and effect until we have received notice of revocation from you. It does not authorize us to make debit entries with regard to any other advance you may now or later obtain from that, or us with regard to this , may recur at substantially regular intervals. You may revoke this authorization to effect ACH debit entries to your account by giving oral or written notice of revocation to us, which, to be effective, must be received by us no later than 3 business days prior to the due date of your advance. However, if you timely revoke the authorization to effect ACH debit entries before the advance is paid in full, you authorize us to prepare and submit one of more checks drawn on your Account on or after the due date of your advance repayment term. This authorization to prepare and submit checks on your behalf may not be revoked by you until such time as the advance is paid in full.

5. By signing below, you acknowledge reading and agreeing to the statements in item 1,2,3 and the authorization in item 4.

6. If this form has been telefaxed to you, you must print your name, date and sign below and telefax this form together with the signed advance, to (714) 917-2261

Terms Of Advance Requested: