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 . What is the note balance? *

8 . Is the person who has left the estate deceased or living? *
Living
Deceased

9 . Is the inheritance $15,000 or more? Please give exact figure (in $). *

10 . When is the inheritance expected to distribute? *

11 . If in a trust, how are the payments due to be paid? *
Not in a trust
Monthly
Quarterly
Semi-annually
Annually
Other

12 . If Other, please explain:

13 . What is the payment amount? *

14 . Do you have any additional comments about this note?

15 . How many payments would you like to sell? *

16 . How much money would you like to get by selling these payments? *

17 . Is this inheritance your only form of income? *
Yes No