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Application for Sale of Personal Injury Claim Proceeds

Plaintiff Information:

Plaintiff's Name:

First Name

Last Name

Plaintiff's Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Plaintiff's Phone Number:

(###)

###

####

Plaintiff's Email:

Plaintiff's Date of Birth:

MM

DD

YYYY

Amount of Money Requested:

Settlement Status:

Select the status of your settlement from the drop-down below

Amount Requesting:

* Format should not include and " , " and be rounded to the nearest dollar amount ( for example $ 5,000.50 would be entered 5000 )

$

Previous Funding Company (and contact info):

if applicable

Have You Filed Bankruptcy?

Check all that apply

I have not filed bankruptcy

I have filed Chapter 7

I have filed Chapter 13

If Bankruptcy Is Applicable, Has It Been Discharged?

Attorney Information:

Attorney Contact Name:

First Name

Last Name

Attorney Firm Name:

Attorney Email:

Attorney Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Attorney Phone:

(###)

###

####

Accident Information:

To be completed by client and/or attorney

Type of Accident:

Date of Accident:

MM

DD

YYYY

State Where Accident Took Place:

Describe Accident and resulting Injuries:

Number:

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