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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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