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Litigation Funding Quick App

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Your Info

First Name: [required]

Last Name: [required]

Street Address:

City:

State:

Zip Code:

E-mail Address: [required]

Home Phone:

Work Phone:

Cell Phone:

Date of Birth:

Attorney Info

Your Attorney's Name:

I don't have an Attorney:

Your Attorney's Phone:

Injury Info

Date of accident/incident:

Type of Case:

Describe how the accident/incident happened:

Medical Treatment Info

Describe your injuries:

Where you in a hospital?:
yes no

If yes, what hospital?:

How many days?:

If any surgeries, describe:

Are you still treating with a Doctor?: yes no

Monetary Need

How much money are you requesting?:

What do you need money for?:

Have you ever received any other cash advances against your current injury claim?: yes no

If yes, how much and from what company:

Applicant Agreement

I, the applicant, hereby certify that the answers given above are true, I am 18 years of age or older, and that my injury claim is true and valid.

I hereby authorize my attorney mentioned above to fully cooperate with Litigation Funding, LLC, and to allow them to review my file and I further authorize my attorney to answer any questions that may be asked, provide to them copies of my file, and I knowingly waive my attorney-client agreement only to the extent necessary to do so.

Type in your name to signify your signature/approval:


Date:


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