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Lottery / Gaming Award Quotation Form

Your Name
Your Email Address
Contact Phone Contact Fax

Award Information Worksheet

Name of Entity Paying You
Type of Payment Being Received Lottery      Vegas-Style Gaming Award   Other Annuity
Current Payment Amount    
This Payment is Being Received  Monthly    Quarterly     Annually  
Total Award Amount (if known) Date of Your 1st Payment
Is This a "Life" Payment   Yes       No      
If Not a "Life" Payment, What is the Final Payment Date?  
Are You Seeking... Total Cash Out    Partial Cash Out
Why Are You Seeking These Funds?  What Are Your Current Needs?
Please answer the math question.   The sum of 9 + 3 =