bold items are required
Full Name:
Email Address:
Phone Number:
Cell Number:
Best Time to Call:
Address:
City:
State:
Zip:
Country:
Type of Payment
(Other, please explain):
Structured Settlement
Lottery
Casino Winnings
Annuity
Other: (Please Explain)
Payment Information
I Receive:
Select...
Monthly
Quarterly
Annual
Other
payments of
First Payment Date:
(Month)
January
February
March
April
May
June
July
August
September
October
November
December
(Day)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Final Payment Date:
(Month)
January
February
March
April
May
June
July
August
September
October
November
December
(Day)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Lump Sum Payments Information
Dates:
Amounts:
Name of Insurance Company or Entity Making Payments to You
Additional Comments or Information:
Check this box if you are human
(Sorry, we have to ask)