Lottery Transaction Information Form:

1. For your benefit, please submit all information as completely as possible. Any omissions may result in an adjustment to our quote(s).
2. All quotes are subject to underwriting review.
3. We will call you with our quote or to request clarification as necessary.

Your Name (First & Last):
Your Street Address:
Your City: State: Zip Code:
Daytime Phone #: (area code first)
Evening Phone #: (area code first)
Fax Phone #:
Your E-mail Address:

The information requested below is the minimum necessary for evaluation of your lottery winnings. Please be as exact as possible with the dates and amounts. Thank you.

Award / Win Date (month, day, year):

Which State is Paying the award?

Total Award Amount: $

Payment Date(s) (month, day):

Frequency of Payments: Select: Please Select Annual Semi-Annual Quarterly Monthly

Total Number of Installments (including 1st payment):

Amount of current payments: $

Amount you receive after taxes: $

Additional Information / Comments:

Your estimated cash requirements: $

( You may not need to sell all your winnings... when a partial sale will meet your needs! )

Thank you for the opportunity to evaluate your lottery cash flow. We will respond to you shortly!