Plaintiff Funding Application II
1. What is your
first name?
*
2. What is your
last name?
3. What is your
phone number?
4. What is your
email?
*
5. What type of case were you involved in?
Select an option
Automobile Accident
Worker's Compensation
Slip and Fall
Wrongful Termination
Other
6. Do you have an attorney?
No
Yes
10.
When
did the
incident
occur?
11.
How much money
do you need?
$
12.
What state
do you live in?
Select an option
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
If you are human, leave this field blank.
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