STRUCTURED SETTLEMENT WORKSHEET

STRUCTURED SETTLEMENT WORKSHEET
Thank you for considering NoteSolutions.us to help you sell your right to receive some or all of your payments. Kindly complete this worksheet so that I can get to work for you. Please note that all information is required unless an item doesn't apply to your situation.
Seller's Information
Date

MonthDayYear
Name

First NameLast Name
Title
Company
Address

Street Address

County

CityState / Province

Postal / Zip Code
Phone

Area CodePhone Number
Fax

Area CodeFax Number
E-mail

Confirmation Email
Payment Information
Payment Type
If "Other," Please Explain
Nature Of Incident
If "Other," Please Explain
Payment Frequency
Payment Amount
Date First Payment Received

MonthDayYear
Date Of Final Payment

MonthDayYear
Periodic Lump Sum Payments Due, If Any
Date

MonthDayYear
Amount
Date

MonthDayYear
Amount
Date

MonthDayYear
Amount
Date

MonthDayYear
Amount
Name Of Company Making Payments To You
YesNo
If So, What Is The Percentage Increase?
Information That Helps Put A Deal Together
Why Do You Want To Sell Your Payments?
How Much Money Do You Need To Raise?
Please Provide Any Comments Or Additional Information You Wish To Share
Thank you for completing this worksheet. If you want to print a copy, please do so before clicking Submit.
Should be Empty:

Seller's Information