New Funding Intake Form

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.

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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?	Yes No
Offer?	Yes No
Trial Date?	Yes No
Mediation?	Yes No
Demand?	Yes No
Appeal?	Yes No

Previous Fundings

Company Name:
Amount:
Payback:

1.866.LIT.FUND

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New Funding Intake Form

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