DailyPay - Underwriting Application

Your Info

First Name

Last Name

Email Address

About Your Business

Applicant – Business or Corporate Name

Additional Trade Name (D/B/A)

Business Street Address, City, State, Zip

Primary Contact Name and Email Address

Year Business Was Established

Federal Tax ID #

Additional Information

Has Applicant or any of its Significant Shareholders (i.e. entities or ultimate beneficial owners that own at least 10% of the Applicant) ever filed a voluntary petition in bankruptcy or been adjudged bankrupt?

Please provide additional details - Bankruptcy

Is the Applicant a Government Entity, meaning a federal, state, municipal, national, local or other governmental department, court, commission, board, bureau, agency, intermediary, carrier or instrumentality or political subdivision thereof, or any entity or officer exercising executive, legislative, judicial, quasi-judicial, regulatory, taxing or administrative functions of or pertaining to any government or any court, in each case, whether of the United States or a state, territory or possession thereof, a foreign sovereign entity or country or jurisdiction or the District of Columbia?

Payroll Questions

How many legal entities will be utilizing DailyPay’s service? If more than one, please provide an organizational chart.

If applicable, please upload org chart.

What entity is the employer of record for eligible employees and responsible for processing payroll?

How many U.S. based, hourly employees did you have on your payroll in the last 30 days?

What is the frequency of your payroll?

What is the average monthly net payroll amount for all of your employees that are eligible for DailyPay services?

Do you operate in states or localities which require you to issue final payments outside of the normal payroll cycle?

What percentage of eligible employees are located in states with final pay regulations or guidelines?

General Terms:

This Underwriting Application (“Application”) is between DailyPay, Inc. (including its successors and affiliates, “DailyPay”) and the Applicant named above (“Applicant”). Applicant acknowledges it is furnishing the information requested herein, including Applicant’s financial statements, for the purpose of DailyPay underwriting the credit risk of the Applicant. Applicant represents and warrants that said information is true and correct and an accurate and complete statement of Applicant’s financial situation. Applicant authorizes DailyPay to obtain credit and financial information concerning Applicant at any time and from any source.

Entire Agreement:

This Application, along with the terms and conditions set forth on DailyPay’s website, www.dailypay.com (“Website”) and Customer Agreement between Daily Pay and Applicant (said Website and Customer Agreement incorporated herein by this reference), constitute the entire agreement between the parties and supersede any terms and conditions set forth on any other documentation submitted to DailyPay by Applicant. Applicant hereby agrees to be bound by such terms and conditions.

Certification:

Applicant certifies that the individual signing below is authorized to execute this Application on behalf of Applicant and acknowledges that, if no such authority exists, then he/she, by executing this document, shall become personally liable under its terms.

Contact Information