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1 .
First Name *
2 .
Last Name *
3 .
Email Address *
4 .
Telephone Number
5 .
Are you personally receiving payments on this note? *
Yes No
6 .
What is the original value of the note? *
7 .
Is the note paid: *
Monthly
Quarterly
Semi-annually
Annually
Other
8 .
If other, explain:
9 .
What is the payment amount? *
10 .
What is the note balance? *
11 .
When was the first payment made on your note? *
12 .
How many payments have been made? *
13 .
How many payments remain? *
14 .
Who issued the annuity (i.e. what company writes you the checks for the annuity)? *
15 .
Is this note assignable? *
16 .
Does this note represent your sole source of income? *
17 .
Please tell us about your needs and expectations so that we may better serve you. *
18 .
How many payments would you like to sell? *
19 .
How much money would you like to get by selling these payments? *
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