CashMax Payday Loan Funding Calculator

Customer Information

Customer First Name*

Customer Last Name*

Vergent Customer ID*

SSN*

Address Line 1*

Address Line 2

Phone Number*

Email Address*

Date of Birth*

City*

State*

ZIP*

Driver's License Number*

Driver's License State*

Driver's License Issued Date*

Driver's License Expiration Date*

Does the customer have a free and clear title?*

Underwriting

Your Vergent Username*

Store Number*

Bank Routing Number (ABA)*

Bank Account Number*

Pay Frequency*

Net Take Home Pay (Per Pay Period)*

Last Pay Date*

Next Pay Date*

Current Bank Balance ($)*

Paycheck Direct Deposited?*

Employer Name*

Employment Type*

Checkless?*

Has Chirp?*

Bank account is at least 1 month old?*

Job is at least 1 month old?*

Residence is at least 1 month old?*

Bank account has 10 or more transactions?*

Does the applicant consistently move their payroll deposits to a different bank account?*

How did you hear about us?*

Print Application: prints the completed form for the customer to sign. Required before submitting.
Clear All Fields: clears the form for the next customer.
Download PDF: downloads a PDF of the filled-out form (including loan status / decision).
Copy Summary: copies decision details to your clipboard for eCheck notes, if necessary.
Copy Decline Reason: copies all decline reasons (one per line).

Print the application first, then press Submit. If you change any field afterwards, you must print and submit again.

Application #

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Loan Status

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Decision

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Approved Amount

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Submission Date & Time

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