Annuity Settlement Payments Submission Worksheet by iamdmx


									   You will be unable to complete this electronic form from your computer. Print and send us the completed form by fax.

                         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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