BOSTON NOTE - Lottory Form

BOSTON NOTE

LOTTERY WINNER FORM

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First Name:		Last Name:

Home Phone:		Work Phone:

Fax Number:		email Address:

State you won in?

Name of the game you won?

Terms of winning, when and how much are you or will you be receiving? Please be sure to include both gross and net (after tax ) amounts and the dates that payments are due.

Have you sold any portion of your winning previously?

Are you interested in selling some or all of your payments?

What is your credit rating?

How did you hear of us?

If through Search Engine, Which one? If Other please specify:

What Keywords did you use?

When you have completed the form please press Submit. To start over please press Reset.

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