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Please Tell Us About Yourself:

First Name

Last Name

Home Phone

Cell Phone

What is the best time to contact you?

Your Address

E-Mail

Type Of Payment

Structured Settlement Annuity

Tell Us About the Payments

Which insurance company (or other entity) is making the payments?

In which state was the lawsuit or settlement made?

I receive payments (monthly, weekly, annually, or other)

If Monthly, Next payment is due (date)

Final Guaranteed Payment Date (for "period certain")

If Periodic Lump Sum Payments, indicate the date followed by the amount of the payment. Place up to 10 payments on new lines.

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