Settlement Information
Type of Settlement:	Choose One Structured Settlement Annuity Lottery
Date of Court Settlement:
Date of First Payment Received:
Amount of First Payment Received:
	(USD)
Date of Last Payment Received:
Amount of Last Payment Received:
	(USD)
Date & Amount of Future Payments to be Received:
How are Payments to be Received:
	Choose One Bi-weekly Monthly Lump Sum Other
For how many years are the payments guaranteed?
	years
Do you have any other source of income? If so, what is it?
Motivation for selling - dollar amount needed:
Name of Insurance Company:
Name of Policy Owner:
State Where Settled:
	State AL AK AS AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY
Cause of Liability: (Personal Injury, Death Benefits, Workers Comp-state Employer or Private)
Do you have a copy of the Annuity Policy?
	Yes No
Do you have a copy of the Settlement Agreement?
	Yes No