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1 .
First Name *
2 .
Last Name *
3 .
Email Address *
4 .
Telephone Number
5 .
What type of prize winning are you selling? *
State Lottery
IGT
Casino Winning
Other
6 .
If Other, please explain
7 .
Have you sold any payments before? *
Yes No
8 .
What was the win date? *
9 .
Were you (the prize winner) the only winner? *
Yes No
10 .
If no, how many other winners were there?
11 .
What percentage did you (the winner) win?
12 .
What was the gross amount won? *
13 .
What is the gross annual payment amount? *
14 .
What is the net annual payment? *
15 .
What state was the prize won in? *
16 .
What state does the prize winner reside in? *
17 .
Are you personally receiving payments on this note? *
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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