Annuity Settlement Payments Submission Worksheet by iamdmx

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                         Settlement Payments Submission Worksheet


Client Information

Name _____________________________ Social Security Number ______________
Address _____________________________________________________________
City _______________________________ State ___________ ZIP ______________
Phone ____________________________ Date of birth _______________________
Driver’s license number and state _________________________________________
Marital status _________________________________________________________
Attorney’s name (if applicable) ____________________________________________

Payment Information

Settlement payor ______________________________________________________
Gross payment amount _________________________________________________
Tax deductions: Federal __________________ State __________________________
Other deductions from gross: Description ______________Amount _______________
Frequency of payments (number of months or years) __________________________
Date of next anticipated payment __________________________________________

Client’s Need

What is the client’s motivation? ___________________________________________
____________________________________________________________________
How much cash does the client need or want? _______________________________




               When you’ve finished filling out the form, fax it to +1 (866) 308-1778

								
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