1.866.LIT.FUND
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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