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New Funding Intake Form





Your Name:
Your Email:
Date:
Funding Request Amount:
Client Name:
Date of Birth
Client Address:
City:
State:
Zip:
Social Security #
Driver's License #
Attorney
Attorney Address:
City:
State:
Zip:
Attorney Phone:
Attorney Fax:
Outstanding Firm or Individual loans and their amounts due:
Type of Case:
Case Status
Lawsuit? YesNo
Offer? YesNo
Trial Date? YesNo
Mediation? YesNo
Demand? YesNo
Appeal? YesNo
Previous Fundings
Company Name:
Amount:
Payback:

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One of our Financial Representatives will be in contact with you once you have submitted this form. If you have any questions, please contact Litigation Funding Corp at 1-866-LIT-Fund.

Litigation Funding