Application Form

Form needs to be filled out completely – all items are required.

First Name:
Middle Name:
Last Name:
Maiden Name (if different):
Address:
City:
State:
Zip Code:
County:
Phone – Home:
Cell:
Work:
Email:
Birth Date:(mm/dd/yyyy)
Social Security Number:
Are You Currently Employed ? Yes No
Can You Maintain Your Standard of Living After Selling Your Future Payments ? Yes No
Do You Have a Disability that Prevents You From Working ? Yes No
Do You Depend on the Settlement Payment(s) for Medical Necessities ? Yes No
Current Marital Status – Single Married Divorced Widowed
Have You Ever Been Divorced ? Yes No
SETTLEMENT INFORMATION
Was your Settlement the Result of a Workers Compensation Claim? Yes No
Have You Ever Sold, Assigned, Pledged, or Borrowed Against the Settlement Payment(s) ? Yes No
Were You a Minor at the Time of the Settlement ? Yes No
Describe the Payment(s) You Wish to Sell:
Specify the Amount of Money You Need to Satisfy Your Financial Need:
Detail the Reason You are Entering into this Transaction –
Be SPECIFIC as to why this Funding is Important to you.
In the Event of the Payee’s Death, Who is Listed as the Beneficiary in the Settlement?
Full Name:
Relationship:
Address:
City:
State:
Zip:
Phone:
Have You Ever Changed the Beneficiary? Yes No