Enter today's date: -- mm/dd/yy

Please provide the following contact information:

Name
Title
Organization
Street Address
City
State/Province
Zip/Postal Code
Work Phone
Home Phone
FAX
E-mail
URL

Enter the State in which prize was won:   

Enter the exact date the prize was won:    -- mm/dd/yy

EXACT total amount of prize won:    $

GROSS payment per year BEFORE tax withholding:    $

EXACT amount of actual check received AFTER taxes:    $

EXACT annual payment date:    -- mm/dd/yy

Total number of installment payments INCLUDING the payment received when the ticket was redeemed:   

Are the payments guaranteed for life ONLY?:    Yes No

If NO, are the winnings guaranteed for a certain specific time (e.g., 10 years, 20 years, etc.)?:

Yes No

If YES, How long?:   

How are the payments being received (what entity)?:    An individual person or husband and wife A Trust A Partnership A Corporation Other

The cash from the sale is needed for what purpose?: 

Would you like a quote to sell:  All of the remaining payments Part of the remaining payments Both

If you selected "part of the remaining payments," Please indicate amount needed  for your situation: $  (we will need to figure how many payments to buy in order to get this amount)

Please rate your level of interest in selling the subject payments:  

Very Interested Would like to sell now Somewhat Interested May Sell Soon Just Curious

Please add any pertinent information that you may want to have considered: