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    Structured Settlement Payments Worksheet






      Client Information

      Date: Name:
      Address: City:
      State: Zip:
      Phone Number: Date of Birth:
      Marital Status: MarriedDivorcedSingle
      Did payment result from a Workers Compensation Claim? YesNo
      Is payment a disability policy? YesNo
      Were you a minor when the case was settled? YesNo
      Insurance Co. Making Payments:
      Payment Information
      Payment Type:
      MonthlyAnnualSemi-AnnualEvery 5 yearsOther (explain below)
      Other explanation:
      Gross Payment Amount:
      Tax deductions:
      Other deductions from gross:
      Frequency of payments (number of months or years):
      Date of next anticipated payment:
      Is the settlement a worker's compensation award? YesNo
      Does the settlement involve child support payments? YesNo
      Additional Comments - Please use this area to provide additional information.

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    • Structured Settlement Payments Worksheet
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      West Bloomfield, MI 48323
      248.948.1800

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