Singer Development Services, Inc.
We purchase cash flows nationwide - Master Consultants                      
107 Meadow Stream Drive - Snyder, New York 14226
716-570-6361  Fax: 716-833-3865  Email: mpsinger@roadrunner.com
www.singerdevelopmentservices.com

STRUCTURED Settlement Payments Submission Worksheet

CCFC/Referral Representative Information
Name:__________________________________________Date:_________________
Company:____________________________________________________________
Address: _____________________________________________________________
City:__________________________________State:________________ Zip:_______
Phone: _____________________________ Fax:______________________________
Email:________________________________________________________________

Client Information
Name on Policy:___________________________________ Date of Birth:__________
Address: _____________________________________________________________
City:__________________________________State:________________ Zip:_______
Phone:_______________________________________________________________ 
Social Security Number:__________________________________________________
Driver’s License # and State:______________________________________________
Marital Status:__________________________________________________________
Name of Beneficiary: ____________________________________________________
Attorney’s name (if applicable):_____________________________________________
Is payment a disability pension?____________________________________________
If so, does disabled pensioner have a second source of income?__________________
Is client providing life insurance? ___________________________________________
If so, amount of coverage_________________________________________________

Payment Information
Structured Settlement Payor: ______________________________________________
Settlement Amount: _____________________ Paid Until When (mo/year):__________
Gross Payment Amount:__________________Paid: __ monthly  __ quarterly __ annually
Tax deductions: Federal _________________________ State____________________
Other deductions from gross: 
              Description____________________________Amount___________________
Date of next anticipated Payment:___________________________________________
Is Settlement Transferrable: _______________________________________________

Client’s Need
What is the client’s motivation?_____________________________________________
How much cash does the client need or want?_________________________________
How many payments does client want to sell:  __ ALL   __ Partial (how many): _______