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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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