First Name:  *

Last Name:  *

Your Time Zone:  *

Best Time To Call You Back w/ Quote:  *

(Area Code) Phone Number:  *

Email Address:  *

Address:  *

City:  *

State: SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming

Zip Code:  *

State or Organization Issuing Lottery Payments:  *

Total Winnings (before taxes):  *

Date Won:  *

Payment Frequency: MonthlyQuarterlySemi-AnnualAnnualOther

Payments are guaranteed through what date:  *

Please List the Due Date and Amount of Each Payment:  *

What type of purchase are you interested in: Full PurchasePartial Purchase

Is there a specific dollar amount you need to raise:  *

Reason for selling your payments:  *

Have you sold any previous payments: NoYes

If Yes to what company:

Do you have and can you supply copies of the following documents:

Lottery Award Letter: NoYes

Copy of most recent lottery check or check stub: NoYes

What is your relationship to this transaction: Annuitant/SellerNote Broker/Note FinderMortgage Broker/Loan OfficerRealtor/AgentAttorney/CPA/Fin. PlannerEstate RepresentativeFamily/Friend

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