Structured Settlement Funding

Structured Settlement Funding Application

Please provide complete and accurate information.
All information will be held strictly confidential.

Contact Information:  
Name Day Phone
Email Eve. Phone
Best time to call Fax
Mail Address City   State Zip  

PAYMENT INFORMATION
Type of Instrument  If Other Explain:
Type of case  If Other Explain:

* Sorry, we cannot purchase Worker's comp, Alimony, Retirement
or Pension based payments.  Payments need to be made by an Insurance Company.
I receive: My monthly payments increase:  
  payments of   % annually on of each year.
Date first payment received:   Date of final payment:
 

Periodic Lump Sum Payments Due:
 Dates:   Amounts:  

Name of the company or agency making payments to you:

Are you currently employed?  

How do you support yourself?

Were you a minor at time of settlement?
How long are your payments guaranteed certain?
My goal is to raise:

Please tell us how receiving a lump sum now will help you:  

Please include any information you think might be helpful:

Marketing Info:

 Please tell us how you found us:

 If by search list keywords used:
 If other please explain: