Clayton & Associates

LOTTERY WINNINGS WORKSHEET
BROKER INFORMATION
BROKER NAME		PHONE
MAILING ADDRESS		CITY
STATE		ZIP
NOTE HOLDER INFORMATION
NAME		PHONE
MAILING ADDRESS		CITY
STATE		ZIP
PAYMENT INFORMATION
THE STATE WINNINGS WERE WON IN
NAME OF CASINO IF A JACKPOT WAS WON
WINNING DATE
TOTAL PRICE ( BEFORE TAXES) $
GROSS AMOUNT OF CHECK $
NET AMOUNT OF CHECK $
DATE OF INITIAL PAYMENT
TOTAL AMOUNT IS PAYED OVER	YEARS
WAS THE WINNING TICKET SHARED WITH OTHERS	YES NO
IF YES HOW MANY
CLIENT WANTS TO SELL ENOUGH PAYMENTS TO RAISE $
ANY ADDITIONAL COMMENTS OR INFORMATION
QUOTE
QUOTE FOR		PAYMENTS
QUOTE FOR FULL PURCHASE $		$
DATE OF QUOTE