Settlement Loan Application

Settlement Loan Application

PERSONAL INFORMATION

Do you have an existing loan with us? *
 Yes 
 No 
Name *

First

Last
Mailing Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone Number *

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Phone Number 2 *

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Email
SS Number *
Date of Birth *

MM
/
DD
/
YYYY

CASE INFORMATION

Attorney Hired & Phone Number *
Please list his/her name as well as the firm he/she works for and the phone number to reach his/her firm
Is your current attorney your original attorney? *
 Yes 
 No 
If no, please list all the attorneys you have had throughout the case and the dates you used them
Claim Type *
 Worker's Comp 
 Personal Injury 
 Other 
Date of Incident *

MM
/
DD
/
YYYY
Defendant/Employer *
Please list who your case is against
Description of the Event *
Please describe the accident, including any injuries that occurred
Prior Injuries *
List any and all injuries you had before the event in question
Does your attorney know you're seeking this loan? *
 Yes 
 No 

LOAN INFORMATION

Amount of Loan Requested *
Purpose of the Loan *
Are you required to pay child support? *
 Yes 
 No 
If yes, please explain how much you pay and if you are behind or on schedule
Are you in bankruptcy? *
 Yes 
 No 
If yes, please list what type of bankruptcy and your attorney
Do you intend to file bankruptcy? *
 Yes 
 No 
If yes, please list what type of bankruptcy and your attorney
Are you involved in any other lawsuits? *
 Yes 
 No 
If yes, please list what type of suit, your attorney, and describe any injuries sustained
Have you obtained any other loans against your settlement? *
 Yes 
 No 
If yes, please list the loan date, amount borrowed, and who the lender is
Where can you sign the loan papers? *
 Sutton Office 
 Your Attorney's Office 
 Other 
If other, please list name of location and fax number
How would you like to receive the funds? *
 Pickup from Sutton Office 
 Regular Mail 
 Priority Mail 
 Bank Wire Tranfer 
 Other 
How did you hear about us? *
 Your Attorney 
 Newspaper Ad 
 Phonebook Ad 
 Internet Search Engine 
 Our Website (www.bobsuttonllc.com) 
 Other 

I certify that information contained in this application is true and complete. I authorize the verification of any or all information listed above.
Do you agree with the terms and conditions? *
 Yes, I agree. 
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Our Location

50 Highway 142
Poplar Bluff, MO 63901
TEL (573) 785-6451
FAX (573) 785-3181
EMAIL operations@bobsuttonllc.com


© 2017 Bob Sutton Real Estate & Loans, 50 Highway 142Poplar Bluff, MO 63901