Application for Sale of Annuity Payments

Application for Sale of Annuity Payments
(print this application and submit to the address listed below)

Applicant's Name ___________________________________________
Street Address _____________________________________________

City ______________________ State ________ Zip _______________

County/Parish ______________________________________________

Home Telephone ____________________________________________

How Long at Current Address _________________________________

States and Counties resided in last 10 years?
States      Counties         Year(s)       States     Counties         Year(s)

__________________________      ____________________________

__________________________      ____________________________

__________________________      ____________________________

__________________________      ____________________________

Current Occupation: ________________________________________

Applicant's Employer: _______________________________________

Address: __________________________________

Phone: ____________________________________

Annual Income: $___________________________________________

Driver's License No.: _______________________ State: ___________

Social Security No.: ___________ - _______ - ___________________

Birth Date: ______/______/_________ Birth State: ________________

Marital Status

Single

Married

Since ___________

Divorced

Widowed

Maiden Name (if different) ____________________________________

Have you been divorced since the settlement? yes no

Divorce Attorney's Name _____________________________________

Address __________________________________________________

City ______________________ State ________ Zip _______________

Phone number _____________________________________________

SPOUSE (Place former spouse's name if divorced or deceased)

Spouse's Name ____________________________________________

Maiden Name (if different) ____________________________________

Driver's License No.: _______________________ State: ___________

Social Security No.: ___________ - _______ - ___________________

Birth Date: ______/______/_________ Birth State: ________________

Address (if different) _______________________________________

City ______________________ State ________ Zip _______________
Next of kin not living with you:
Name _________________________ Relation ____________________

Address __________________________________________________

City _______________________ State ________ Zip ______________

Phone (include area code) ____________________________________

Two Non-Family References

Name__________________________ Phone _____________________

Address __________________________________________________

City _______________________ State ________ Zip ______________

Name__________________________ Phone _____________________

Address __________________________________________________

City _______________________ State ________ Zip ______________

Settlement Attorney's Name___________________________________

Address __________________________________________________

City _______________________ State ________ Zip ______________

Telephone__________________________ Fax ___________________

Please detail below the reason you are entering into this transaction. Be specific as to why this funding is important to you.

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

__________________________________________________________

Specify the amount of money you need to raise to satisfy your financial need.

__________________________________________________________

__________________________________________________________

__________________________________________________________

Annuity is a result of: (Check One)

Please list all sources of income.

____________________________________________

Do you depend on the Annuity payments for medical necessities?

____________________________________________

Describe the payments you wish to sell.

____________________________________________

Can you maintain your standard of living after selling you annuity payments?

Do you have a disability that prevents you from working?

Yes No
If yes, please explain.

____________________________________________

Has your annuity ever been garnished?

Yes No
If yes, please explain.

____________________________________________

Have you ever sold, assigned, pledged or borrowed against your annuity payments?

Yes No
If yes, please explain.

____________________________________________

Do you have any tax liens or unpaid taxes?

Yes No
If yes, please explain.

____________________________________________

Do you have any unpaid child-support obligations?

Yes No To Whom: _________________________
If yes, please specify amount and term remaining.

____________________________________________

Do you have any liens or judgments against you?

Yes No
If yes, please explain.

____________________________________________

Have you ever filed bankruptcy?

Yes No
If yes, detail when and where and attach proof of discharge.

____________________________________________

Are you currently involved in litigation?

Yes No
If yes, please describe.

____________________________________________

Have you ever been convicted of a felony?

Yes No
If yes, please explain.

____________________________________________

Annuity Information

Insurance Company that makes your payments

Name ______________________________________________

Do you have an Account Representative?Yes No

Name of Account Representative __________________________

Telephone _____________________________________________

Policy Number __________________________________________

Policy Owner's Name ____________________________________

Who is listed as the Annuitant on the policy?

______________________________________________________

Who is listed as Measuring Life on the policy?

______________________________________________________

Who is listed as Payee on the checks?

______________________________________________________

In the event of the Annuitant's death, who is listed as Beneficiary on the policy?

Name _________________________________________________

Address _______________________________________________

City ________________________ State ______ Zip ____________

Phone Number __________________________________________

Does the Settlement Agreement specifically allow for a change of Beneficiary? Yes No

Have you ever changed the Beneficiary? Yes No
If yes, from whom to whom and when was the change made?

_______________________________________________________

To what address or bank does the Insurance Company now send the payments?

Name ___________________________________________________

Address _________________________________________________

City ________________________ State ________ Zip ____________

Home Attorney's Office Direct Deposit

For monthly payments, what day of the month do you usually receive your annuity payment?

__________________________________________________________

What is the date of the final guaranteed payment?

__________________________________________________________

Do payments continue after the guaranteed period for the life of the Annuitant? Yes No

Was your settlement the result of a workers compensation claim?
Yes No

Besides the Annuitant, were others listed as plantiffs in the original Settlement Agreement? Yes No
If yes, who? _______________________________________________

__________________________________________________________

Do you have a Will? Yes No
If yes, who is the named beneficiary of your Annuity Payment?

__________________________________________________________

Where did you first hear about us?

__________________________________________________________

Required for funding. PLEASE ATTACH TO APPLICATION

The Annuity Policy
The Executed Release / Settlement Agreement
A copy of your most recent Annuity Check or Check Stub. If direct deposit, attach copy of bank statement showing deposit
A copy of front page of most recent tax return
Copies of two forms of identification (one must be clear photo I.D.)
A copy of Marriage License (if applicable)
A copy of Divorce Decree(s) / and property settlement(s) (if applicable)
A copy of Will and Probate Papers if you are receiving payments as the result of a probated estate
A copy of the Court Judgment (if applicable)
Copies of any Assignments, Revisions, or other important papers related to the Annuity or Settlement Agreement, and Bankruptcy discharge papers, if applicable

Authorization to Conduct Credit and Criminal Background Check

I hereby authorize the designated representative to conduct any and all criminal background checks and any and all credit history reports, searches, or checks which it, in its sole discretion and judgment, deems necessary or advisable.

Authorization to Release Information

I hereby authorize the designated representatives or any of their successors, assigns, designees, agents or administrators to disclose, make available and furnish to them any and all information pertaining to my settlement as set forth. I specifically direct that the Annuity Issuer and Annuity Owner, or any of their successors, assigns, designees, agents or administrators cooperate with the purchasing company listed below regarding disclosure of information pertaining or related to my settlement. Please provide copies via fax or otherwise of any and all documents requested by the company listed below regarding my settlement. This also authorizes Settlement Capital to contact next of kin for data resources.

Acknowledgement of Fraud Prevention System Inquiry

I hereby acknowledge that the National Association of Settlement Purchasers maintains records of individuals who sell, assign or otherwise hypothecate structured settlement annuity payments. I authorize you to check the records of said association for such activity.

By signing below, I / we certify that all of the information provided above is true and correct. I / we understand that any intentional misrepresentation on my / our part will result in the immediate cancellation of the assignment.

Applicant's Signature ___________________________________

Date _______ / ________ / ________

Spouse's Signature ___________________________________

Date _______ / ________ / ________

Return to:
Diversified Discount Buying Resources
1822 4th Ave. W.
Seattle, WA 98119
206-281-3153 * Fax206-378-1070
www.FredCoutts.com