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Disclaimer:

I hereby authorize the designated representatives or any of their successors, assigns, designees, agents or administrators to disclose, make available and furnish to Legal Funds Now any and all information pertaining to the settlement of my case as set forth. I specifically direct that the attorney representing me in my case or any of the successors, assigns, designees, agents or administrators cooperate with Legal Funds Now regarding disclosure of information related to the settlement of my case. I also authorize Legal Funds Now to pull consumer credit reports and any information concerning liens and judgments against me. Please provide copies via fax or otherwise of any and all documents requested by Legal Funds Now. I also request that my attorney share his candid opinion of my case with Legal Funds Now By submitting this form, I/we certify that all of the information provided above is true and correct. I/we understand that any intentional misrepresentation on my/our part will result in the immediate cancellation of any assignment or purchase made in connection with this application.

We do not fund Workers Compensation Cases in the following states: Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Illinois, Kansas, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, New Hampshire, New Jersey, New York, North Carolina, North Dakota, Oklahoma, Pennsylvania, South Carolina, Tennessee, Utah, Vermont, Virginia, Washington DC, and Wisconsin.