Pre settlement and structured settlement funding

^*Required Your Contact Information

First Name^*

Last Name^*

Address^*

City^*

State^* [Select] Alabama Alaska Arizona Arkansas CaliFornia Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Indiana Iowa Kansas 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

ZIP Code^*

Email^*

Phone^*

How did you hear about us?^* [Select] Attorney Referral Television Radio Mailer Newspaper Other Print Ad Web Ad Search engine Other

Information About Your Case

Advance Requested^* Unknown $5,000 or less$5,001 to $10,000$10,001 to $25,000$25,001 to $50,000$50,001 to $100,000$100,001 to $250,000

Select the Type of Case^* [Select] Anti-Trust Auto Accident Aviation Accident Boating Accident Breach of Contract Casino Winnings Child Custody Class Action Construction Discrimination Divorce Environmental Harm Jones Act Loss Profits Lottery winnings Negligence (Medical and Legal) Other Patent Infringement Personal Injury Phen-Phen Product Liability Securities Fraud Settled Case Structured Settlement Workers Compensation Wrongful Death Wrongful Termination Vioxx Zyprexa

Attorney Name^*

Attorney Phone^*

Name of Attorney Firm^*

Date of Accident^*

City where it happened^*

State where it happened^* [Select] Alabama Alaska Arizona Arkansas CaliFornia Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Indiana Iowa Kansas 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

Date of Birth (mm/dd/yy)^*

By checking this box I hereby authorize and specifically direct my attorney(s) and any designated representatives or any of their successors, assigns, designees, agents or administrators to disclose, make available and fully cooperate with Baric Funding("Baric Funding") upon Baric Funding's request any/all information pertaining to the settlement of my case. Please immediately provide copies via fax or otherwise of any/all documents requested by Baric Funding. I also request that my attorney share his candid opinion of my case with Baric Funding.
By submitting this application for advance cash on my settlement, I certify that all of the information provided above is true and correct. I acknowledge that I understand the benefits of non-recourse funding.
By clicking on the Submit button I indicate that I have read and agree to the Authorization to Release Information.

You must check this box to have your application processed. This gives us permission to contact your attorney and review the merits of your case. All information is held strictly confidential

Digital Signature initials and last 4 of social