Personal Information:

*First Name: *Last Name:

*State: *Zip Code *Phone Number: Cell Phone:

Email Address:

*Are you at least 18 years of age? Select Yes No

*Attorney name:

*Attorney Telephone Number:

Attorney Email Address

*Lawsuit Type: Select Type Personal Injury Motor Vehile Accident Slip and Fall Wrongful Death Defective Products Motorcycle Accidents Railroad Cases Other *Incident Date:

*State of Incident:   Other:

*Amount Requested:

*Have you ever obtained cash or funding from another company in regard to this case? Select Yes No

*Have you ever changed attorneys in this case? Select Yes No

*Have you declared bankruptcy? Select Yes No

*May we contact your attorney? Select Yes No

If you check yes, you hereby authorize your attorney to release to a representative of Lawsuit Cash Funding, any portion of your file that Lawsuit Cash Funding may require related to the incident date referred to above in this application.  You acknowledge that you understand the benefits and detriments of non-recourse funding and further understand the effects of disclosing the contents of your file, including waiver of the attorney-client privileges. You MUST check the "yes" box to have your application processed.

SUBMISSION OF THIS APPLICATION DOES NOT GUARANTEE THAT LAWSUIT CASH FUNDING WILL OFFER TO FUND A PORTION OF YOUR CASE OR THAT YOU ACCEPT ANY POTENTIONAL FUNDING OFFER POSSIBLY MADE BY LAWSUIT CASH FUNDING.

* - required fields