a
* Required Field
* Annuitant's Name:
* Phone/Cell:
* Email Address:
* Annuitant's Address:
* Are You Personally
Receiving These
Payment(s)
Yes
No
* Exact Name &
Address of Insurance
Company Making
Payment(s):
* Payment Amount:
* Payments Made:
Monthly
 Quarterly
 Semi-Annually
 Annually
* # Of Payments
Remaining:
*Annuity Resulted
From What (Personal
Injury, Investment,
Lottery Winnings, etc.) :
* Current Age of
Annuitant:
**List all of the EXACT
payment dates
(mm/dd/yy) and
amounts for the
payments you wish to
sell (EXACT DATES
ONLY - no estimates
please):
* Why Are You Selling
Your Payments:
* How Much Money Do
You Need:
* When Do You Need
The Cash By:
Comments:
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