The following information are needed for us to grant your request in selling your annuity lottery winning payments. 

You may submit this form to us by printing it out and mailing it to us or you can call and tell us the information and we will contact you within 48 to 72 hours with a "lump sum" quote based on the information you provide us below.

What type of prize was it? _________________________

__ State Lottery __ Casino Winning __

      Other (Specify) _______________

Have you sold any payments before? __ Yes __ No 

    If YES, to what company? ______________________

What was the Win Date? _______________________

Were you the only Winner? __ Yes __ No

    If No, how many other winners ______________

What % did you win? ____________________

What was the gross amount won? ___________________

What is the Gross Annual payment amount? ____________

What is the Net Annual payment? ______________________

What state was the prize won in? ______________________

What stste do you reside in? _________________________

How many payments would you like to sell? _____________

How much money are you looking to obtain? ____________

Print and mail this sheet to: