You may submit this form to us by printing it out and faxing it to us and we will contact you within 48 to 72 hours with a "lump sum" quote based on the information you provide us below.

What type of prize was it? _________________________

__ State Lottery __ Casino Winning __

      Other (Specify) _______________

Have you sold any payments before? __ Yes __ No 

    If YES, to what company? ______________________

What was the Win Date? _______________________

Were you the only Winner? __ Yes __ No

    If No, how many other winners ______________

What % did you win? ____________________

What was the gross amount won? ___________________

What is the Gross Annual payment amount? ____________

What is the Net Annual payment? ______________________

What state was the prize won in? ______________________

What stste do you reside in? _________________________

How many payments would you like to sell? _____________

How much money are you looking to obtain? ____________

_________________________