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:    
*Home Address:
*City: *State: *Zip code:
*Phone Number (Day):   Phone  Number
  (Evening):
  Fax Number:   Email Address:
*Date of Birth   SS#:

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

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

  Law Firm's Name:        
*Attorney handling case:        
*Address:
*City: *State: *Zip Code:
*Phone Number:        
  Fax Number:        
  Email address:        
  Paralegal handling case:        
  City, State of Court:        
     B. *Case Type: (for example, Auto Accident, Personal Injury, Slip & Fall, Product Liability, Fraud, Breach of Contract,
              Medical Malpractice, Employment Discrimination, Pharmaceutical Litigation, Wrongful Death, Workers' Compensation,
              Commercial, etc.)

      C.   Case Details:

       D.   Accident Information (if applicable):

Name(s) of defendant(s):
Date & Time of accident or injury:
City, State where accident or injury occurred:
4. INSURANCE & SETTLEMENT INFORMATION

Defendant's insurance carrier:

Last settlement offer from defendant to you:
Last settlement demand from you to defendants:
5. LIENS & ASSIGNMENTS ON YOUR CASE: Please indicate the liens & assignments (if any) on your case.  If you do not have a lien, write "NONE" in the application box.
Attorney fees (i.e. the percentage of recovery or fixed amount of fee):

Insurance liens:

Medical liens:
Other liens or assignments:
6. ADDITIONAL INFORMATION:

*Currently in bankruptcy?

 Yes No

*Changed attorneys in this case?

 Yes No
*Obtained a prior advance on this case? Yes No
*If your answered "yes" to any of the
  above questions, please explain:
7. CERTIFICATION: The information provided in this application is true, accurate, and complete, to
the best of my knowledge and belief:
* Name: * Date:

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 * Date