IMPORTANT NOTE: PLEASE COMPLETE FORM IN ITS ENTIRETY FOR CONSIDERATION.

Cash Advance Request Form

Please Provide As Much Information As Possible

All Information Is Strictly Confidential

        Your Information

Full Name
Street Address
Apartment #
City
State/Province
Zip/Postal Code
Day or Work Phone
Home Phone
Cellular Phone
FAX
E-mail
Mother's Maiden Name
Social Security Number
Date of Birth
Driver's License Number
State DL License Issued
Marital Status
Advance Amount Requested

           Use of Proceeds: (What you are going to use the cash advance for):

Case Description

City Where Incident Occurred
State Where Incident Occurred
Incident Date

            Automobile Accident        Wrongful Death           Breach of Contract

            Product Liability                Wrongful Eviction        Medical Malpractice

            Sexual Harassment          Class Action                Wrongful Termination

            Slip And Fall                      Wrongful Arrest           Securities Fraud

            Discrimination                   Dog Bite                      Negligence

            Fraud                                  Slander                        

            Other                                  

          What Occurred?: (Explain Briefly)

          Describe Your Injuries:

Medical Bills: (Amount To Date)
Name of Insurance Company
Coverage Amount
Defendant's Name: (Whom You Are Suing)
Lawsuit Filed: (Yes or No)
Date Lawsuit Was Filed
Case Value: (Your Opinion)

Attorney Information

Attorney's Name
Firm Name
Paralegal's Name
Street Address
Suite #
City
State/Province
Zip Code
Office Phone
Cell Phone
Other Phone
FAX
E-mail

          Case Liens To Date       

             Lien Holder:                                             Lien Date:                                Lien Amount:

                          

   Lien Holder:                                             Lien Date:                                 Lien Amount:

                          

   Lien Holder:                                             Lien Date:                                 Lien Amount:

                          

   Lien Holder:                                             Lien Date:                                 Lien Amount:

                          

   Lien Holder:                                             Lien Date:                                 Lien Amount:

                          

   Lien Holder:                                             Lien Date:                                 Lien Amount:

                          

        Additional Information:

Submit Form Now Or Call Us @ 813-854-2300

Westshore Mortgage & Investments Co., Inc. 

8140 W. Waters Avenue, Suite C, Tampa, FL  33615

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