Lottery Winnings
Quote Request

 
For a quote on selling us your future lottery payments, please fill out the form below. Please include any questions you have and we will respond promptly.
Contact Name:
My Relationship to Recipient is that I am the:
E-Mail:
Address:
City:
State: Zip:
Phone #1:
Phone #2:
Awarding State:
Prize Claimed by:
Exact Win Date:
Exact Prize Amount :
Gross Annual Payment Amount (before tax):
Net Annual Payment Amount (after tax):
Exact Annual Payment Date:
Number of Payments Received:
Number of Payments Remaining:
 
If you have any comments please state them in the box below.
How did you find us?

Referred By: (for Affiliate or Broker use)

Affiliate/Broker:

E-Mail:

Phone:

FAX:

  

 

 Return to Main Page without Submitting This Form