New Sel Prel N ller liminary Inform y mation

Contac Informa ct ation ***All information below is required, including alternate c i contact inf formation.
First Nam _______ me: ___________ ________ Last Name: _ ___________ __________ ___________ __ Referred By: ______ ___________ __________ ___________ __ ddress: ____ ___________ __________ ___________ __________ _ Street Ad City: ___ ___________ __________ ___State____ ______ Zip Code: _____ __________ ____ Best Tim of Day to Contact: ___ me ____AM __ _______PM Email Ad ddress: ____ ___________ __________ ______ Phon #:_______ ne __________ ___________ ____ Alternate Email addr e ress: ______ ___________ __________ ___________ __________ ___________ ____ Alternate Phone #___ e __________ ___________ __________ ___________ __________ ___________ ____

Quote Informat tion

Agreed upon Purchas Price: $__ u se __________ _____ Gross Mo onthly Amou of Paym unt ments to be so $______ old: _________ Amount of Monthly Payments de evoted to Sa $______ ale: ___________ __ Length of Term: ___ o ________Mo onths Total Mo onthly House ehold Incom $_______ me: __________ _ Name of Pension Company: ____ f __________ ___________ __________ ________ If Militar please lis Branch and Rank: ___ ry, st d ___________ __________ ___________ __________ _ Method of payment from your pe o f ension comp pany: Direct Deposit:____ EFT D T/ACH:____ Wire Trans _ sfer:____ Pa aper Check:_ ____ Other:______ O ___________ __________ ___________ __________ ___________ ____

Paym method information is importan because o each pensi company has different ment d n nt of ion y proce esses and req quirements for changing the destinat f tion of the pa ayments you receive. u PLEA FIND OUT WHAT THIS PRO ASE O T OCESS WITH YOUR PE H ENSION CO OMPANY INCL LUDES NOW IN ORDE TO PREV W ER VENT DELA AYS WHEN THE CAS IS CLOSE TO N SE E CLOSING.

Life Co ontingent Payments Informat s tion **If you payment are life contingent which is to say, you must be a ur ts c t, u alive to rec ceive them, pl lease fill out the follo owing infor rmation.
Do you currently hav Life Insur c ve rance: Yes__ ____ NO___ __
If NO, Please Note: You will be co Y ontacted to put this in pla p ace. If YES, you MUST at y ttach the Dec clarations Pa of your E age Existing Life Insurance Policy. We mu ust have this BEFORE th process ca move forw his an ward. Face amount of Existin Life Insura ng ance Policy (If Applicable) $_________ If ): _________

Date of Birth: _____ B ___________ ___ Do you have a valid Drivers Lic h cense _____ Yes _____ N No Do you use tobacco in any form or fashion? ___ Yes ___ No If so, how? _____ u i _ _ ___________ ____ Have you been convi u icted of a fel lony within the last five (5) years? _ t _____ Yes __ ____ No

Please note th this for must be fully com hat rm e mpleted bef efore proce eeding and d sub bmitted to your Case Manager y e r