Structured Settlements & Annuities

Structured Settlement & Annuities Application

Please complete all fields below. Your information is protected with SSL encryption and kept strictly confidential. A funding specialist will review your application and contact you within 24 hours.

Structured Settlement / Annuity / Lottery / Casino Application

Personal Information

Please provide your personal contact information below.

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone Number

Funding Request

Please provide your funding request details below.

How Much Lump Sum Cash Do You Need Now?

Name of the State Agency, Company, or Insurance Provider Making Payments to You Now?

Payment Information

Please provide your current payment details below.

How Much Is Your Payment That You Currently Receive?

Your Current Payment Is Received

Date of Your First Payment

Payment 1 — Due Date

Payment 1 — Amount

Payment 2 — Due Date

Payment 2 — Amount

Payment 3 — Due Date

Payment 3 — Amount

Additional Information

Please provide any additional information below.

What Are Your Current Needs?

Additional Comments

Certification & Submit

Please review your application and certify the information below.

Certification

I certify that all information provided is true and accurate to the best of my knowledge. I authorize First Capital Financial Group, LLC, its funding sources, agents and/or assigns to contact me regarding my application. This is futher confirmed by my typed name below which acts as my signature.

Today's Date

First Name

Last Name