Contact Person:

Email:

Phone:
(include area code)

Fax:
(include area code)

Payment Information

Payment Type:
(if other, please explain below)

   Lottery Winnings Casino Winnings Other - (Please explain) -

I receive:

Payments of:

Date first payment received:

Date of final payment:

Periodic Lump Sum Payments Due:

Dates:                    Amounts:

Name of the insurance company or state/agency making payments to you:

Any Additional Comments or Information: (Such as how many payments you want to sell, amount you want to receive, etc.)