Personal Information
*Full Name:
Date of Birth (MM/DD/YYYY):
Address:
Address 2:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
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:
*E-Mail Address:
Home Phone:
Work Phone:
Cell Phone:
Attorney Information
Attorney's Full Name:
Name of Law Firm:
Phone Number:
Fax Number:
Address:
City:
State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
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:
Law Firm Contact (paralegal/legal assistant):
Funding Information
Amount of Funding Requested:
By submitting this form, I agree that all the information listed is accurate and correct. In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed without it.
Enter your ATTORNEY'S NAME here:
I request and authorize my attorney to provide ALN Capital Services, LLC with whatever information (whether oral or in writing) needed to evaluate my funding request. I specifically waive any privilege that I may have regarding such information.
I hereby request and authorize your firm to cooperate with and release to ALN Capital Services, LLC any and all information and documents pertaining to my case. Please share your candid opinion regarding this action with ALN Capital Services, LLC, so that ALN Capital Services, LLC can evaluate my funding request.
I acknowledge that I understand the benefits and risks of non-recourse funding. I further acknowledge that I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges.
Thank you in advance for your cooperation.
Name:
Date:
By clicking here, you indicate that you have read and agree to the Records Release Authorization. You must check this box for your application to be processed. This authorization gives us permission to contact your attorney and discuss your case with your attorney. We charge a $250 application fee, only for funding requests which we approve and only for cases in which we provide funding. The application fee is not due until you receive your settlement or award at the end of your case. If you lose your case, you owe us nothing.
By submitting this form, I agree that all the information listed is accurate to the best of my knowledge.