*Denotes required field

 Contact Information
* Name
 Address Line 1
 Address Line 2
 City
 State:
 Zip Code
* Day Phone
* Evening Phone
 Fax
 E-Mail
 Seller's name
 State of winning or settlement
 
 Kind of Settlement
Personal Injury VSI/VA disability
Lottery Law firm receivable
Third party/workers comp Royalties
Other (please explain briefly)
 
 Monthly Payments
 Do you have monthly payments?  Yes    No
 Payment amount $
 Total number of payments  
 Beginning date Yr
 End date Yr
 Percent increase (if applicable) %
 Increase occurs  Annual
 Every   years
 Annuity (insurance) company
 Payments issued by  Direct Deposit    Check
 
 Lump Sum Payments
 Do you have lump sum payments?  Yes    No
 Date of payments Amount
Yr $
Yr $
Yr $
Yr $
Yr $
 
(shaded area)  For Military Retirement/VSI/VA Disability Only
 
 If disability:
What is the disability and its extent?
 
 Gross Amount $
 
 If military:
Pay Grade 		Rank Branch of Service
 
 Tax deductions from Gross: Federal tax $ State tax $
 
 Other deductions from Gross:
 Describe   Describe
Amount $    Amount $
 Net Pay $
 
 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:
 
 How did you hear about us?
 
 
 To help in our marketing efforts, please give us the name of the publication, station, search engine, person, etc. which led you to our web site.
 
 If you found us through a search engine on the internet, please tell us which words you typed to locate our site.
 

 Additional Information/Comments:
 

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Advance Funding buys and  pays cash for mortgages, notes, seller financed mortgages, FSBO, settlements, liens, mobile home notes, royalty payments, trust deeds, privately held mortgages, lease options, business notes, legal settlements, lotteries, annuities, real estate notes, inheritances, portfolios, car paper, commercial loans, and other notes that originate in the United States only. If you have questions please contact us for further details.
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