| Covered Borrower Identification Statement
Federal law provides important protections to active duty members of the Armed Forces and their dependents. To ensure that these protections are provided to eligible applicants, we require you to select one of the following statements as applicable by checking the appropriate box:
IMPORTANT INFORMATION ABOUT PROCEDURES
To help the government fight the funding of terrorism and money laundering activities,
Federal law requires us to obtain, verify, and record information that identifies
each borrower. When you apply for a loan, we will ask for your name, address, date
of birth, and other information that will allow the lender to identify you. We may
also ask to see your driver's license or other identifying document.
ARE REQUIRED BY LAW TO ADOPT PROCEDURES TO REQUEST AND RETAIN IN OUR RECORDS INFORMATION
NECESSARY TO VERIFY YOUR IDENTITY.
I submit to Dollar Financial Group, Inc. and
its affiliates d/b/a The Check Cashing Store® ("Lender") this application for the
purpose of inducing Lender to extend or maintain credit to me. I certify that this
application presents a true, complete and correct statement of the matters shown
as of the date of my application and does not omit any pertinent information. I
understand that misrepresenting information on this application may be a criminal
offense. I will notify Lender promptly in writing of any material unfavorable change
in this information. In the absence of such notice, Lender may consider this a continuing
application and substantially correct. If I apply for further credit, this application
shall have the same force and effect as if delivered as an original application
at the time I request such further credit. Lender is authorized to contact credit
reporting agencies and other sources for the purpose of verifying any information
stated herein or at any time furnished by me to Lender. I authorize Lender to utilize
and retain any information about me in Lender’s records previously provided by me
for use by any other lender. I understand that this application and any other information
furnished to Lender shall be the Lender’s property. Lender is authorized to answer
any questions about Lender’s experience with me.
Each of the parties voluntarily
agrees to have all claims or controversies that arise from or relate in any way
to our past, present or future business with each other, and with its or his respective
affiliates, agents or employees, including the validity of any related agreements
and the scope of this arbitration clause, resolved by BINDING ARBITRATION by a single
arbitrator in accordance with either the JAMS Streamlined Arbitration Rules & Procedures
or the Commercial Rules of the American Arbitration Association, as elected by me.
This arbitration agreement is made pursuant to a transaction involving interstate
commerce and shall be governed by the Federal Arbitration Act, 9 U.S.C §§ 1-16.
The parties understand that they have a right or opportunity to litigate disputes
through a court, but that they prefer to resolve their disputes through arbitration.
IF ARBITRATION IS CHOSEN, I WILL NOT HAVE THE RIGHT TO GO TO COURT, TO HAVE A JURY
TRIAL, TO PARTICIPATE AS A REPRESENTATIVE OR MEMBER OF ANY CLASS OF CLAIMANTS, OR
TO HAVE MY CLAIMS CONSOLIDATED OR JOINED WITH THOSE OF ANY OTHER CLAIMANT. I WILL
HAVE VERY LIMITED RIGHTS TO PRETRIAL DISCOVERY AND APPEAL. I understand that Lender
will only consider my application if I agree to the terms of this paragraph.