Pension Quote Request Form

Pension Cash Value Quote Request

*You must receive a minimum NET payment of $550 per month to apply.

Complete the form below and we'll send you a FREE Estimate of CASH Available to you. Be sure to complete each field and please enter only correct information.

IMPORTANT: On December 16, 2003 H.R. 2297 legislation was enacted restricting our ability to purchase VA DISABILITY and MILITARY payments. WE NO LONGER PURCHASE VA DISABILITY PAYMENTS.

First Name

Last Name

Street Address

City

State Zip

Day Phone

Evening Phone

Fax

Email

Type of Pension *We Do Not Purchase VA Disability Payments.

Explain if Other Type of Pension

Rate Your Credit *If credit does not qualify, co-guarantors are accepted.

Number of Pymts. You Want a Quote for *We can purchase the next 6 or 12 monthly payments.

Other Source of Income *Must be employed or have other income. (Spouse income OK)

Please enter a brief description
for the purpose of these funds.

Please enter where you heard about US.

Please Fill in the amounts that you currently receive.
Please Note that we keep all information in strictest confidence.

PLEASE ENTER ONLY "MONTHLY AMOUNTS"

Gross Monthly Pymt. Taxes Withheld Allotments Withheld Other
Withheld

*Net

Pymt.

*Your NET payment amount must be a minimum of $550 per month to apply.

Referred By: (for Affiliate or Broker use)

Affiliate/Broker:

E-Mail:

Phone:

FAX:

First Name
Last Name
Street Address
City
State	Zip
Day Phone
Evening Phone
Fax
Email
Type of Pension	*We Do Not Purchase VA Disability Payments.
Explain if Other Type of Pension
Rate Your Credit	*If credit does not qualify, co-guarantors are accepted.
Number of Pymts. You Want a Quote for	*We can purchase the next 6 or 12 monthly payments.
Other Source of Income	*Must be employed or have other income. (Spouse income OK)
Please enter a brief description for the purpose of these funds.
Please enter where you heard about US.