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Application for Sale of All or a Portion of your
 STRUCTURED SETTLEMENT OR ANNUITY

  First Name      
  Middle Name   
  Last Name   
  Address  
  Address Line 2  
  City  
  State  
  Zip  
       
  Home Phone  
  Work Phone  
  Cell Phone  
  Fax  
  Email  
1. Have you ever had a serious head injury?  Yes    No  
       
2. Please list any current significant health problems:    
     
       
3. Do you depend on your payments for medical necessities?  Yes    No  
       
4. Do you have a disability that prevents you from working?   Yes    No  
  If YES, What is it?       
       
5. Marital Status
( Please check one )		 Single  Married  Divorced  Widowed  Separated    
       
6. Married How Long:     /years    
       
7. Have you ever been divorced? Yes    No  
       
8. Do you pay child support? Yes    No  
       
9. Do you have any liens or judgments against you? Yes    No  
       
10. Have you ever filed for Bankruptcy? Yes    No  
       
11. Do you have any tax liens or unpaid taxes? Yes    No  
       
12. Have you previously sold, assigned or borrowed against your Structured Annuity payment or have your payments been garnished?    Yes    No  
       
13. Is there any other individual entitled to a portion
of your payment?		 Yes    No