Name of Borrower: __________________________________________________________________________
Name of Co-Borrower: _______________________________________________________________________
Auto, Boat, RV, Motorcycle & Personal Loans*: Account Number and Loan Suffix Number Required
Loan #1
$25
Account Number: ________________ Loan Number: __________ Payment Due Date: __________
Loan #2
$25
Account Number: ________________ Loan Number: __________ Payment Due Date: __________
Loan #3
$25
Account Number: ________________ Loan Number: __________ Payment Due Date: __________
The undersigned borrower and co-borrower/guarantor (if applicable) hereby make application to extend the original repayment
terms of the loan(s) referenced here by one month. Any extension will not otherwise alter the original terms and conditions of the
loan contract as previously disclosed to the borrower. Interest will continue to accrue on the unpaid balance of the loan at the
agreed rate. All applications are subject to Orion’s approval.
You agree and understand that: 1) Loans must have originated at least 180 days prior to be eligible; 2) All borrowers who originally
signed the loan documents must agree to the Skip-A-Pay program and sign this request and a Subsequent Action Form; 3) If we are
unable to stop any preauthorized ACH payment in time, your skipped payment may be delayed until the next scheduled payment; 4)
FINANCE CHARGES will continue to accrue at the rate provided in your original loan agreement, during and after this time; 5)
Deferring your payment will result in you having to pay higher total FINANCE CHARGES than if you made your payment as originally
scheduled; 6) The payment deferral will extend the terms of your loan(s), and you will have to make extra payment(s) after your
loan(s) would otherwise be paid off; 7) You will be required to resume your payments the following month; 8) A minimum of three
loan payments must be made between skipped payments; 9) Only Loans that are 15 days or less past due are eligible; 10) If you
elected GAP or Warranty/Mechanical Repair Coverage, the coverage will not be extended beyond the original maturity date; 11) You
must pay $25 for each loan indicated above upon application; if your application is denied, the amount will be refunded to your
account. Certain restrictions may apply.
*Excludes all Real Estate Loans, Holiday Loans, Education Loans, Business Loans, and any loan that has been granted an extension in
the past 12 months.
Signature Borrower: ________________________________________________ Date: __________________
Signature Co-Borrower: _____________________________________________
Date: __________________
Expires 12/31/16