Lottery Worksheet

Information on Lottery Winner:
Full Name:
Phone:
Current Address :
City:
State:
Zip Code:
Prior Address:
City:
State:
Zip Code:

Lottery Information
Date of Lottery Award:
 
Date of First Payment:
 
Total $ Amount Won in lottery:
  (USD)
Date of Last Payment:
 
$ Amount of annual lottery payments:
  (USD)
Date & Amount of Future Payments:
How many more years will the payments be received?
  years
Do you have any other source of income? If so, what is it?
Motivation for selling - dollar amount needed:
Number of additional winners/partners:
 
State of Lottery:
 
Do you have a copy of the Award letter?
 


Your Contact Information (Needed so that we may contact you with purchase offers)  
Your Name:
E-mail*: (Required OR tel #)
Phone Nr*: (Required)
Fax:
Current Address:
City:
State:
Zip Code: