Application

In this Advance Application (herein referred to as the "Application"), the words "you" and "your" mean the Applicant identified below. The words "we," "our," "us," and "The Cash Store" mean Cottonwood Financial Utah, LLC.

Red Labels represent REQUIRED fields.

Applicant Information

Name (Last, First, Middle)	Social Security #	Driver License / ID	Date of Birth (MM/DD/YYYY)
Address	Apt #	P.O. Box Address	City
State	Zip	Own/Rent/Other	How long at Address?
Home Phone Number	Home Phone is in Whose Name?	Mobile Number	Alternate Number
E-mail:

Income Information *

*Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Employment Type	Employer	Employer Phone Number:	Position
Employer Address:		Employer City / State / Zip
Length of Employment Years Months	Pay Frequency	Last Date Paid	Next Date Paid
Take Home Pay*	Direct Deposit	Wage Garnishment	Day of Week Paid

Additional Income Information * (Complete only if you want this income to be considered for credit purposes)

*Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Source's Name	Social Security #	Source's Address / City / State / Zip (if different from above)
Employment Type	Employer	Employer Phone Number:	Position
Employer Address:		Employer City / State / Zip
Length of Employment Years Months	Pay Frequency	Last Date Paid	Next Date Paid
Take Home Pay*	Direct Deposit	Wage Garnishment

Bank Information

Bank Name:

Checking Account #:

How Long Has It Been Open?
Years Months

Personal References (We will not contact your references to qualify your loan)

Personal Reference - Nearest relative not living with you
Name	Relationship
Street Address	Apt. #
City,State, Zip	Home Phone Number

Personal Reference
Name	Relationship
Street Address	Apt. #
City, State, Zip	Home Phone Number

How Did You Hear About The Cash Store?

Newspaper	Radio	Flyer/Handout	Friend	Internet	Direct Mail	Billboard	Store Sign
Television	Yellow Pages	Other (explain)

Do you want to visit The Cash Store nearest your home or your work?

Home Work No Preference

Can we contact you upon receipt of this application?

Yes

If yes, what is the best to reach you?

Home Number

Mobile Number

Arbitration

Arbitration is a means for legal matters between parties to be resolved by a neutral arbitrator rather than a Court. The Cash Store has a policy of arbitrating all claims, demands, and disputes which cannot be resolved in a small claims tribunal, including the scope and validity of this arbitration provision and any right you may have to participate in an alleged class action (hereinafter “dispute(s)”). All customer agreements contain another arbitration provision that supersedes this arbitration provision and governs the resolution of disputes. However, if you do not enter into a customer agreement with us, then this arbitration provision governs the resolution of disputes. You agree that YOU ARE WAIVING YOUR RIGHT TO HAVE A TRIAL BY JURY to resolve disputes against us, our agents and/or owners. The Federal Arbitration Act governs this arbitration provision. If either party has a dispute, they must notify the other in writing of the dispute. You have the right to select any of the following arbitration organizations, which will govern the arbitration under its consumer rules: American Arbitration Association (1-800-778-7879) http://www.adr.org, J.A.M.S./Endispute (1-800-626-5267) http://www.jamsadr.com, or National Arbitration Forum (1-800-474-2371) http://www.arb-forum.com, and we will advance all of the expenses associated with the arbitration, including the filing, administrative, hearing and arbitrator’s fees. You will be responsible for your attorney’s fees, if any. Any appeal of a judgment from a small claims tribunal shall be resolved by binding arbitration. The arbitrator shall not conduct class arbitration. The arbitration hearing will be conducted in the county in which this Application was signed.

Important Information - Please click here to view and print Privacy Policy
	I verify that I have read the privacy policy

Marketing Information (Optional)**

Total Household Income (Include all wage earners in the home):

Educational Background:

How many dependents at home:

How far do you LIVE from our store?

How far do you WORK from our store?

Which radio station do you listen to?

**The information you provide in the Marketing Information section is purely voluntary on your part. The information you provide will assist The Cash Store to better serve you. The Cash Store does not use your responses in the Marketing Information section as a part of the credit decision process during your advance request.

Additional Information

Pursuant to Section 7-23-105 of the Utah Code:

Cottonwood Financial d/b/a The Cash Store is regulated by the State of Utah Department of Financial Institutions. Utah residents may contact the Department of Financial Institutions at (801) 538-8830. For questions, comments or complaints, please contact us at (877) 217-4547 or email compliance@cottonwoodfinancial.com.

Common Questions:

What is the cost of credit? The cost of credit equals $20.00 per $100.00 borrowed for a period of 14 days. This equals 521.43% APR. Please refer to the fee schedule below for examples.

What are my payment options? There are five (5) payment options.

* You can extend your advance for an additional two weeks. Simply issue a new check for the two-week period and pay the finance charge in cash. We will return your check for the original advance. An advance can be extended up to five (5) times.
You can extend your advance, but pay additional cash towards your balance and that will reduce the balance that is extended. Because the smaller amount is extended, you will save money.
You can come in to the store and pay the full amount of the advance on the due date. Immediately after any advance is paid off, you can get another, possibly for a higher amount.
You can come in to the store and pay off the advance in cash before the due date. By coming in before the due date you can save money. The earlier you come in, the more you save.
If you do not perform one of the above options by your due date, your check will be deposited as payment for your advance.

Can I pay early? Yes. See the different type of payment options above.

Fee Schedule
Advance Amount	Finance Charge**	Check Amount**	APR**
$100	$20	$120	521.43%
200	40	240	521.43%
300	60	360	521.43%
400	80	480	521.43%
500	100	600	521.43%
600	120	720	521.43%
700	140	840	521.43%
800	160	960	521.43%
900	180	1,080	521.43%
1,000	200	1,200	521.43%
1,100	220	1,320	521.43%
1,200	240	1,440	521.43%
1,300	260	1,560	521.43%
1,400	280	1,680	521.43%
1,500	300	1,800	521.43%
* Depending on state regulatory guidlines ** Finance Charge, Check Amount (Total of Payments), and Annual Percentage Rate (APR) are for cash advances with a term of 14 days.
Early repayment of cash advance may result in a refund of the unearned Finance Charge.

Read Before Signing

You agree that you have read and understood all the above statements, including the Arbitration Provision.

You certify the information supplied by you on this form is true and correct. You authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above, and fully release all parties from all liability for any damage that may result. Any false statement made above shall be sufficient basis for rejection. You certify that you have read and understand the above statement.

You certify that you have received, reviewed and understand Cottonwood Financial's Privacy Policy and Notice.

WE MAY REPORT INFORMATION ABOUT YOUR ACCOUNT TO CREDIT BUREAUS. LATE PAYMENTS, MISSED PAYMENTS, OR OTHER DEFAULTS ON YOUR ACCOUNT MAY BE REFLECTED IN YOUR CREDIT REPORT.

I verify that I have read the above terms and conditions

Security

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