1. 1. Hand Written Application Form
  2. 2. Attorney Document Request Letter
  3. 3. Hand Written Attorney Questionnaire Form
  4. 4. Online Attorney Questionnaire Form
  5. 5. Authorization to Release Confidential Information
  6. 6. Authorization to Release Medical Records (“HIPPA”)
  7. 7. Example Pre-Settlement Funding Agreement # 1
  8. 8. Example Pre-Settlement Funding Agreement # 2



Apply for Funding

To apply for lawsuit funding, please complete the form below and we will process your request immediately.

Applicant Name *

Phone #1 *
- -
Email address *

Date of Birth

Postal Address *

City*

State *
Type of Case *

Have you Received Previous Advance?
Yes     No
if Yes how Much? *

Attorney Name *

Attorney Phone Number *
- -
Attorney Fax
- -
Attorney Email

How much money do you need?
Describe the Incident?
Describe the Injuries Sustained?


I have read and agree to the terms of the Authorization to Release Information

Already completed an application with us?

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