PLAINTIFF FUNDING APPLICATION
Instructions: Please fill out as much as you can. If you do not know the answers to certain questions, we can obtain the information from your attorney later. Fields marked with ( *) are required.

1. CLAIMANT INFORMATION:

*Full Name

Required
*Home Address
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*City
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*State
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*Zip Code
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*Phone # (Day)
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Phone # (Evening)
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Fax Number
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*E-mail
Required
*Date of Birth
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SS#

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*2. Amount of Money Requested Please indicate the amount of money you would like.

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3. LAWSUIT INFORMATION: Tell us about your case.
A. Attorney & Case Information:

Law Firm's Name
Please type your full name.
*Attorney handling case
Required
*Address
Required
*City
Required
*State
Required
*Zip Code
Required
*Phone Number
Required
Fax Number
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E-mail address
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Paralegal handling case
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City, State of Court
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B. Case Type: (for example, Auto Accident, Personal Injury, Slip & Fall, Plane, Train, Ship & Boating Accidents, Employment Discrimination, Wrongful Termination, Medical Malpractice, Pharmaceutical Litigation, Wrongful Death, Wrongful Arrest, Workers' Compensation, Whistle blower (Qui Tam) etc.)

C. Case Details

Required
6. ADDITIONAL INFORMATION:
*Currently in bankruptcy?
Required
*Obtained a prior advance on this case?

Required
If your answered "yes" to any of the above questions, please explain

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7. CERTIFICATION: The information provided in this application is true, accurate, and complete, to the best of my knowledge and belief:
*Name
Required
*Date
Required

Easy Lawsuit Funding

Phone: 626-792-9897 Fax: 626-304-0833
We require certain information regarding your claim or lawsuit for our underwriting process. Please sign this Records Release, authorizing your attorney to share information about your claim or lawsuit with us.
I hereby authorize my attorneys to release to Easy Lawsuit Funding, or its affiliates, any and all information and documents pertaining to my current claim or lawsuit, in order to help fund my case.


*Full Legal Name
Required
*Date
Required