How To Get A Cash Transfer From A Deceased Spouse To A Deceased Person

Transcription

1 Broker or other Referral Source Information: RAPID SETTLEMENTS, LTD. National Processing Center 5051 Westheimer Suite 1875 Houston, TX / Toll-Free 877/ Fax 877/ APPLICATION FOR CASH FOR FUTURE PAYMENTS Name: Relation to Applicant (broker, attorney, advisor, etc.): Firm Name: Phone: Day: ( )- Evening: ( )- Cell: ( )- Mailing Address: Fax: City State Zip APPLICANT INFORMATION Applicant Name: Address: Phone: Day: ( )- Evening: ( )- Cell: ( )- Street Address: City County State Zip Mailing Address: (if different from street address) List all states and counties resided for the past five (5) years: Have you been known by any other name(s) than that stated on your settlement or annuity?. Yes No If yes, specify name(s): Current Occupation: Current Employer: Employer s Address: Employer s Phone: Wage level ($x/hr; $x/2wks): Annual Income: Date Hired: Social Security Number: Date of Birth: State of Birth: Driver s License Number: Driver s License State: Current Marital Status:... Single Married since Divorced Widowed Have you been divorced or widowed since the settlement?.. Yes No If yes, former spouse s name: Divorce Attorney: Describe the injury or sickness for which you are receiving payments: Explain in detail why you want to complete this Transfer: Specify the amount of money you need to satisfy your current financial need: How did you hear about Rapid Settlements, Ltd. / Rapid Funding, LLC? Application for Cash 01/2009 Rapid Settlements, Ltd. Page 1 of 1

2 DEPENDENT INFORMATION Current Spouse (if married) Spouse s Name: Maiden Name: Current Occupation: Current Employer: Employer s Address: Employer s Phone: Wage level ($x/hr; $x/2wks): Annual Income: Date Hired: Social Security Number: Date of Birth: State of Birth: Driver s License Number: Driver s License State: Children or Other Legal Dependents Name: Age: Lives with Applicant? Yes No Name: Age: Lives with Applicant? Yes No Name: Age: Lives with Applicant? Yes No Other Dependent-Related Information Closest relative who does not live with you: Name: Phone: Address: Relation: Also provide a reference from a friend or other person who is not a member of your family: Name: Phone: Address: Known how long? ANNUITY INFORMATION Name of Insurance Company that makes payments to you: Phone Number: Policy Number: Policy Owner s Name: Who is listed as the beneficiary on the policy: Does the Settlement Agreement specifically allow for a change of beneficiary? Yes No Where does the insurance company send the payments: Final guaranteed payment date: Do payments continue for your life after that date? Yes No The annuity is the result of (check one):.. Court Judgment Out of Court Settlement Other Was your settlement the result of a workers compensation claim?. No Yes, provide the following: Defendant: Settlement Date: Primary Injury: Do you depend on the annuity payments for medical necessities or living expenses?. No Yes (explain): List all sources of annual income and their respective annual amounts: List the future payments (with amounts and payment dates) that you desire to sell (e.g., $1,000 per month from 1/1/2004 to 12/1/2009, one lump sum of $100,000 due on 7/1/2008, etc.): Can you maintain your standard of living after selling the annuity payments listed above?... Yes No Have you sold the annuity payments described above to another company?.. Yes No Are you currently trying to sell the annuity payments described above to another company?... Yes No If yes, to what company? Application for Cash 01/2009 Rapid Settlements, Ltd. Page 2 of 2

3 Please explain any Yes answers to the following questions and attach supporting documentation Do you have a tax lien or unpaid and past due taxes? No Yes: Do you have any past due alimony or child support obligations?. No Yes: Do you have any liens or judgments against you? No Have you ever filed bankruptcy? (if yes, attach discharge) No Are you currently involved in litigation?. No Have you ever been convicted of a felony?. No Are you prevented from working due to a disability?.. No Has your annuity ever been garnished? No Have you ever sold, assigned, pledged, or borrowed against your annuity payments?. No Yes: Are there any Federal, State, or local taxes withheld from your annuity payments? No Yes: Have you been adjudicated incompetent?.. No Application for Cash 01/2009 Rapid Settlements, Ltd. Page 3 of 3

4 ATTACHMENTS REQUIRED FOR APPLICATION TO BE APPROVED The Settlement & Release Agreement (or most recent proposal if denied, with a copy of the court denial) The Annuity Policy or Contract Clear copy of your driver s license or other photo identification Clear copy of your social security card Copy of your most recent annuity check, check stub, or direct deposit verification Copy of your most recent federal tax return (Form 1040 without additional forms or attachments) Copy of the court judgment (if applicable) Copies of any assignments, revisions, or other changes related to the annuity or Settlement Agreement Copy of bankruptcy discharge papers (if applicable) Copy of marriage license (if applicable) Copy of divorce decree(s) and/or property settlement(s) (if applicable) Copy of the Order Approving Minor Settlement (if you were a minor at the time of settlement) Copy of the will and probate papers (if you are receiving payments from a probated estate) Other documents may be required on a case-by-case basis AUTHORIZATION, ACKNOWLEDGEMENT & CERTIFICATION 1. By signing below, I/we certify that all of the information provided in this application and all attachments hereto are true and correct. As the Applicant, I certify the following: (i) I am at least 18 years of age; (ii) I am not a convicted felon; (iii) I am not currently in bankruptcy or planning to file bankruptcy in the near future; and (iv) I have not been adjudicated incompetent. I/we understand that any intentional misrepresentation on my/our part will result in a breach of my agreements with Rapid Settlements, Ltd.. 2. By signing below, I/we acknowledge that I/we was/were provided a copy of Rapid Settlements Privacy Policy and Other Terms & Conditions that is included with this Application. 3. By signing below, I/we agree to immediately notify Rapid Settlements, Ltd. of any change in my/our address and/or phone number throughout the term of the application and transfer assignment. 4. By signing below, I/we authorize all financial institutions, insurers and similar persons (or any of their successors, assigns, designees, agents, or administrators) to furnish to Rapid Settlements, Ltd. any and all information pertaining to my structured settlement/annuity financial instrument. I/we further direct that the Annuity Issuer and Annuity Owner fully cooperate with Rapid Settlements, Ltd. regarding the disclosure of my/our information to Rapid Settlements, Ltd. 5. By signing below, I/we authorize Rapid Settlements, Ltd. to conduct such background checks that Rapid Settlements, Ltd. in its sole discretion and judgment deems necessary or appropriate for this transaction, including but not limited to: (i) criminal background check; (ii) credit history check; (iii) employment and income verification; and (iv) reference checks. 6. By signing below, I/we agree to the attached Privacy policy and Other Terms & Conditions in consideration of which Rapid Settlements, Ltd. agrees to process your application and transfer, which Privacy policy and Other Terms & Conditions are incorporated herein for all purposes. I acknowledge receiving a copy (attached). Applicant s Signature Date Spouse s Signature (if married) Date Application for Cash 01/2009 Rapid Settlements, Ltd. Page 4 of 4

5 RAPID SETTLEMENTS, LTD. PRIVACY POLICY AND OTHER TERMS & CONDITIONS At Rapid Settlements, Ltd. ( Rapid Settlements ), we understand your concerns about the privacy of information you provide us as part of this application and transfer process. Be assured that we only collect information we believe is necessary or appropriate to expedite the transfer of your structured settlement payment(s) so that we can fund your transaction as quickly as possible. INFORMATION COLLECTED All information collected is kept in a secured facility protected by fingerprint recognition door access and other safeguards. There are generally three categories of information collected: Information provided by you on applications, forms, and in attachments thereto; Information available as a matter of public record such as prior court transfer activity; and Information you authorize us to collect such as background checks and credit checks INFORMATION DISCLOSED OR SHARED Your information will only be shared with or disclosed to third parties, such as our attorneys, which we work with as part of the application process. Rapid Settlements may share or disclose your information to third parties, as allowed by law, only for the following reasons: Disclosure of information is necessary to expedite, effect, process, or administer your transfer; Disclosure of information is requested by law enforcement, a court of competent jurisdiction, or a governmental entity as part of any investigation; or Disclosure of information to businesses we use to develop internal security and privacy practices with regard to both our physical facilities and our client database We will not disclose your information to third parties for marketing purposes without your prior consent. ADDITIONAL INFORMATION This Privacy Policy may change from time to time. We will inform you of any changes as they are made. If you need more information about this Privacy Policy, please call us toll free at (877) or your questions or concerns to info@rapidsettlements.com initial Application for Cash 01/2009 Rapid Settlements, Ltd. Page 5 of 5

6 TERMS & CONDITIONS In consideration of Rapid Settlements agreement to process your application and pursue the transfer of your structured settlement payment rights or similar future payments ( Periodic Payments ), you hereby grant and convey to Rapid Settlements a ten-day right of first refusal beginning upon Rapid Settlements receiving actual written notification of an offer to purchase or otherwise acquire any Periodic Payments, as follows: If you receive an oral or a written offer to sell, assign, borrow against, pledge or otherwise encumber any Periodic Payments and you desire to enter into a transaction involving the sale, assignment, borrowing against, pledging, or other encumbrance thereof, you agree to immediately notify Rapid Settlements, Ltd. in writing: (a) that you have received an offer; and (b) describing in detail all terms of said offer along with providing all writings evidencing such. You agree to direct any other purchaser to directly pay over to Rapid Settlements fifteen percent of the amount of Periodic Payments transferred by you to a person in breach of this paragraph. In connection with this right, you grant Rapid Settlements an interest in all your Period Payments. You authorize Rapid Settlements (or its assigns) to file in the UCC records a notice as Rapid Settlements finds appropriate of the existence of the rights of Rapid Settlements described above. You refers to the applicant named herein. This agreement and any disputes generally between Rapid Settlements (or its assignee) and Applicant will be governed by the laws of Texas and that Texas is the proper place of venue to bring any cause of action arising out of a breach of the agreement. Any dispute or disagreement between these parties arising under this agreement or otherwise of any nature whatsoever including, but not limited to, those sounding in constitutional, statutory, or common law theories as to the performance of any obligations, the satisfaction of any rights, and/or the enforceability hereof, shall be resolved through demand by any party and/or interested party to arbitrate the dispute in Texas in and under the laws of the State of Texas and shall submit the same to a neutral arbitration association for resolution pursuant to its single arbitrator, expedited rules. If the first arbitration organization, which receives a written demand for arbitration of the dispute from any party and/or interested party, does not complete the arbitration to finality within four months of the written demand, any party and/or interested party then may file a written demand for arbitration of the dispute with another neutral arbitration association, with the prior arbitration association then being immediately divested of jurisdiction, subject to a decision being rendered by the replacement arbitration association within four months of the written demand being filed with the replacement arbitration group. The arbitration decision shall be final and binding in all respects and shall be non-appealable. Any person may have a court of competent jurisdiction confirm the arbitration award as a judgment of such court and enter into its record the findings of such arbitrators for all purposes, including for the enforcement of the award. The parties hereto waive the right to trial by jury in any action or proceeding instituted with respect to this agreement. The parties hereto agree that the issue of arbitrability shall likewise be decided by the arbitrator and not by any other person. That is, the question of whether a dispute itself is subject to arbitration shall be decided solely by the arbitrator and not, for example, by any court. In so doing, the intent of the parties is to divest any and all courts of jurisdiction in disputes involving the parties, except for the confirmation of the award and enforcement thereof. initial R:\forms\templates\application v11 rsl.doc Application for Cash 01/2009 Rapid Settlements, Ltd. Page 6 of 6