By its nature, issues involving the purchase of future payments require the answers to some personal questions.
You have our assurance that any information shared with us will not be released
to any outside agencies or persons.
Please fill out total form to the best of your ability but those items with blue names are optional.
Click Submit when you are through.


PERSONAL INFORMATION

Name
Home Phone Number
Work Phone Number
Address
City
State
Zip Code
E-Mail Address
Type of Asset?
If "Other", Describe
Royalty
Annuity
Lease
Note on Airplane, Boat or RV
Other Describe

INFORMATION FOR NOTE ON AIRPLANE, BOAT OR RV
(If not a NOTE skip this section)

Please describe the asset
(Include model and year)

Terms Of The Sale

Date of Sale
Sales Price
$
Down Payment
$
Amount Financed
$

Terms Of The Note

Date of Note
Original Balance
$
Term of Note
 Months
Interest Rate
 %
Monthly Payment
$
First Payment Date
Last Payment Date
Next Scheduled Payment Date
Number Payments Remaining
Have All Payments Been On Time?
Yes No
Credit of Borrower?
Unknown
Below Average Average Above Average
Quote Desired
If Partial, Indicate Amount of Cash
Desired Now
Total Buyout of Remaining Contract
Partial Buyout  $ Partial Amount

INFORMATION FOR ROYALTY, LEASE OR ANNUITY CONTRACT

Date of Contract
Description of Paying Entity
(Individual, Corporation, Insurance Company, ASCAP, BMI, etc)
Original Contract Value
$
Original Term of Contract
(Specify Years, Quarters, Months)
Payment Frequency
Annually Quarterly Monthly
Other Describe
Payment Amount
$
Please describe Changes to Payment Over Time
(Contingencies, Escalators, etc)
First Payment Date
Last Payment Date
Next Scheduled Payment Date
Number Payments Remaining
Please Describe any other Contract Terms you think would be useful in determining the Contract Value
Quote Desired
If Partial, Indicate Amount of Cash
Desired Now
Total Buyout of Remaining Contract
Partial Buyout  $ Partial Amount

            

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If you have any questions, please contact Steve Story at
steve@storyfinancial.com or call toll free at (800) 480-3928