Apply to Sell Your Pension

Please use this form to provide us with more detail on the pension you wish to sell. Please fill in only the questions that apply to you! You will be contacted after your application has been reviewed.

CONTACT INFORMATION

Your Name

Your Email

Address Line 1

Address Line 2

City and State

Zip Code

Daytime Phone

Evening Phone

Fax

Seller's Name

State of winning or settlement

SETTLEMENT INFORMATION

Type of Settlement

If you selected other, please explain

MONTHLY PAYMENTS

Do you have monthly payments?
 Yes No

Payment Amount

Total number of payments

Payment Start Date (MM/DD/YY)

Payment End Date (MM/DD/YY)

Payment Increase (if applicable)

How often does this payment increase occur?

Annuity (insurance) company

Payments issued by
 Direct Deposit Check

LUMP SUM PAYMENTS

Do you have lump sum payments?
 Yes No

If so, what are the dates and dollar amounts of payments?

FOR MILITARY RETIREMENT/VSI/VA DISABILITY ONLY

If you are disabled, what is the disability and its extent?

Gross Amount

If military, what is/was your pay grade, rank, and branch of service?

Tax and other deductions from gross, including federal and state

Net Pay

- END MILITARY/VSI/VA DISABILITY ONLY SECTION -

Do you want to sell all payments?
 Yes No

I want to sell enough payments to raise:

Are you able to work?
 Yes No

Reason you are selling

Additional notes, information, concerns or comments

How did you hear about us?