APPLICANT'S PERSONAL INFORMATION

	*Date of Application:
*Full Name:	*Home Phone:
*Address:	Cell Phone:
*City:	Work Phone:
*State: *Zip Code: pick a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	*Email:
*Date of Birth: Social Security #:	Referral Source: Choose.. Brochure Attorney Client Other

EMPLOYER / DEFENDANT INFORMATION

Employer / Defendant:

Employer / Defendant Address:

Employer / Defendant City: State: Zip Code: pick a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ATTORNEY INFORMATION

Lawyer's Name: Phone: Firm Name: Fax:

Address:

City: State: Zip Code: pick a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ACCIDENT / INCIDENT INFORMATION

Date of Accident / Incident: Case #: Type of Case: Choose.. Personal Injury Workers Compensation Civil Rights Wrongful Termination Other

Describe The Accident /Incident:

2nd Accident (If Applicable): Case #: Type of Case: Choose.. Personal Injury Workers Compensation Civil Rights Wrongful Termination Other

Describe The Accident /Incident (If Applicable):

WORKERS COMPENSATION (IF APPLICABLE)

Insurance Carrier (Work Comp):

Applicant's Average Weekly Wage: Applicant's TTD Wage (if applicable): Total Period of Lost Time:     Did Insurance Carrier Pay Lost Time Benefits (TTD)? choose one Yes No N/A Did Insurance Carrier Pay Medical Benefits? choose one Yes No N/A Is Applicant Presently Working? choose one Yes No N/A Is Applicant Still Employed with Employer? choose one Yes No N/A

MEDICAL TREATMENT (IF APPLICABLE)

Did the Applicant have an MRI? choose one Yes No Is the Applicant Still Treating? choose one Yes No Did the Applicant Have Surgery? choose one Yes No

Describe The Medical Treatment:

INJURY INFORMATION

Describe The Injures Sustained:

ADDITIONAL QUESTIONS

Is the Applicant Receiving Social Security or Medicare Benefits?	If So, When?
choose one Yes No Has Applied For
Is the Applicant Receiving Public Aid Benefits?
choose one Yes No Has Applied For
Is the Applicant Paying Child Support?
choose one Yes No
Has the Applicant Filed for Bankruptcy (Chap 7 or Chap 13)?	If So, When?
choose one Chapter 7 Chapter 13 No
Has Applicant Ever Been Convicted of a Crime?	If So, What Crime?
choose one Yes No
Has Applicant Ever Been Incarcerated?
choose one Yes No

MONEY INFORMATION

How Much Money is Applicant Seeking?

What Does Applicant Need the Money For?

OTHER LOANS

Has the Applicant Taken Out Any Other Loans or Cash Advances Against Their Case(s)?	If So, When?
choose one Yes No
If So, Where is the Loan From?	How Much Money Was the Loan For?

Applicant certifies that the answers given in this application are true and correct to the best of his/her knowledge and that he/she is at least 18 years of age. Applicant acknowledges this application is part of SMP Advance Funding's loan approval process. False and misleading statements will be sufficient reason for SMP Advance Funding to terminate any loan agreement and require immediate payment of any loan entered into by Applicant and SMP. *Signature: *Date: