Name

Email address

Phone number

What is the best time to reach you?

What type of prize winning was it?

State Lottery
IGT Casino Winning
Other (specify)

Have you sold any payments before?

Yes
No

If yes, to what company?

What was the Win Date?

Were you the only winner?

Yes
No

If no, how many other winners?

What % did you win?

What was the gross amount won?

What is the gross annual payment amount?

What is the net annual payment?

What state was the prize won in?

What state do you reside in?

How many payments would you like to sell?

How much money are you looking to obtain?