Date: Advance Amount:
Attorney:
Firm Name:
Type of Practice:
Address:
City: State: Zip:
Email Address:
Phone Number:    Attorney Fax Number

Outstanding Firm or Individual loans and their amounts due:

Lines of credit and their amounts due:

Number of cases pending on a contingency basis:
Number of cases offered as collateral of non-recourse advance:

Quality of cases - Please provide the attorney questionnaire and supporting documents for each case
that will be used as collateral for the advance via mail, email, or fax us at (248) 948-1802.

One of our Financial Representatives will be in contact with you once you have submitted this form.
If you have any questions, please contact Lawsuit Financial at 1-877-377-SUIT or email us.