Annuities DELMarVA Judgment Services

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Annuity Worksheet
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*Name:*
*Address:*
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*State:*
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*Work#:*
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*Home#:*
*Best time to call:*
*How did you hear of us:?*

*Email:*
Information about your Annuity
*What is the payment amount?:$*
*Payments Made:*
*Total number of payments:*
*Number of payments remaining:*
*Is your contract assignable?:*
Start date of your payments:
End date of your payments:
*Have you had any payments?*
If yes, how many have you had?:
If yes, what was the reason?
*Is your annuity a result of?:*
*Why do you want to sell?:*
*How much cash do you need?*
*Do you have another source of income?:*
Comments:	What else can you tell us?
Check if you have these documents:
Annuity Policy:
Contract:
Supporting documents:
The data, which we collect from you is not an application for credit. The intent of this form is for us to determine if a relationship between DELMarVA Judgment Services and/or its assigns and you and/or your company would be mutually beneficial. By submitting the required form, you authorize DELMarVA Judgment Services and/or its assigns to access any credit reporting agencies for which we are a member in your security interest under any agreements and transactions relating to DELMarVA Judgment Services and you and/or your firm. Your information is held in the strictest confidence and is used to help you achieve your goals in an expeditious and professional manner. _____________________________________________