You can  submit information to us about your income stream to get a faster quote! If you are ready to convert your payments over time to a lump sum of cash, simply follow the steps below:

1. From the list below select the cash flow debt instrument that you would like to get a Free No Obligation Valuation.

2. Submit your email address.

3. Completely Fill out the worksheet and submit for your valuation. Call us for other worksheet .

FOR NO OBLIGATION CONSULTATION

 Call us @ 1-888-865-3017

E-mail us @ taxandfinance@aol.com

CCFC/Broker Information

Name______________________________________________ Date_________________

Company_________________________________________________________________

Address ________________________________________________________________ City_______________________________ State ___________ ZIP___________________

Phone ____________________________  Fax___________________________________

Real Estate Information

Street address ______________________ County________________________________

City _____________________ State_____ ZIP___________________________________

Current estimated value $_____________ Based on______________________________

         Residential                                   o  Single-family                                 o  Multi-family

                                                              o  Owner-occupied                           o  Rental  

         Commercial         Description ____________________________________________

                                                              o  Owner-occupied                           o  Rental

         Vacant land         Description ____________________________________________    

Description of Real Estate Property & Area__________________________________

___________________________________________________________ ___________

Historical Information                                    Prior Mortgage Information (if any)

Date of sale         ____________                   ______________

Selling price      $ ____________                                                                          

Down payment $ ____________                                                                                  

First lien            $ ____________                                                                    

Second lien       $ ____________                   ______________

Note Information                                                Payor Information

Date of note            ________________        (Employment info, payment history, 

Amount                $  ________________         SSN) __________________             

Term in months       _____ (a) _____ (b)                                         

Payment amount $  ________________                                                                

Balloon amount   $  ________________                                                                  

Balloon date            ________________                         

Interest rate             _______________%       Seller’s Motivation/Need

Due date 1st pmt    ________________                                                                  

# of pmts paid         ________________                                                        

# of pmts left           ________________                                          

Next pmt due           ________________                                                        

Balance                $ ________________     ___________________________________

                                                                                            I have copies of the following:

Quote                                                                               Note                        o Yes o No

                                                                                          Security instrumento Yes o No

Buy Total Note                  $ ____________________     Title                         o Yes o No 

Buy _____ pmts for          $ ____________________     Sales contract        o Yes o No

Buy _____ pmts for          $ ____________________     Payor credit report  o Yes o No 

Date of quote                       ____________________     Closing statement  o Yes  o No

Closing costs paid by          ____________________     Bill of sale               o Yes  o No

                                                                                          Insurance               oYes   o No 

                                                                                          Appraisal                oYes   o No 

                                                                                          Prior mortgage infoo Yes  o No 

                                                                                          Payment history     o Yes  o No

 CCFC/Broker Information

Name_________________________Company_______________________ Date_________

Address ___________________________________________________________________

City________________State____ ZIP_______Phone _____________Fax______________

Provider Information

Provider name______________________________________________________________

Present address ____________________________________________________________

City ___________________ County__________________ State _____ZIP_____________

Phone______________________________________ Fax___________________________

Contact name_______________________________  Title __________________________

Type of facility    o Physician         o Hospital                        o SNF

                         o Long-term care o Durable Medical Equipment o Other___________

Structure           o Corporation     o  Partnership                  o Sole Proprietorship           

License number ____________________ Federal Tax ID number____________________

Administrator/Owner________________________________________________________

Chief Financial Officer_______________________________________________________

Director of Patient Accounts/Business Office____________________________________

Director of Data Processing__________________________________________________

Manager of Collections______________________________________________________

What liens exist against the accounts receivable?

      Bank             o No                 o Yes                        Amount__________________

     IRS                o No                  o Yes                        Amount__________________

     Other             o No                  o Yes                        Amount__________________

Why does Provider desire to sell receivables? ___________________________________

How long does Provider desire to continue selling receivables?______________________

How much cash is requested at initial funding?___________________________________

Is there current or pending litigation against the Provider?    

Does Provider do its own payroll?____________ or use third party (name)?____________

Are payroll taxes current?__________________ If not, amount delinquent_____________

Are Federal taxes current? _________________ If not, amount delinquent_____________

Are State taxes current?            If not, amount delinquent__________________________

Has Provider ever had a Medicare offset?___________ Amount of offset_______________

Amount of previous offset(s) remaining unpaid____________________________________

Is there a Medicare offset pending?________________ Estimated amount_____________

Date of last cost reporting filing________________________________________________

Please complete other side.

What is the average number of insurance claims billed per month?

      Inpatient___________________________   Outpatient__________________________

What is the average dollar amount of insurance claims billed per month?

      Inpatient___________________________   Outpatient__________________________

What is the average total amount billed to insurance payors per month? (Complete below).

Payor type         Monthly Average Billed                Net Collectible Value       Average days to Pay

Commercial insurance  _______________      _____________%       _________________

Medicare                     _______________      _____________%       _________________

Medicaid                     _______________      _____________%       _________________

HMO/PPO                  _______________       _____________%      _________________

Workers Comp            _______________       _____________%      _________________

What is the total amount of unpaid insurance claims aged less than 91 days in the above financial classes? _________________________________

Please attach a summary page from the aged trial balance.

/medical

CCFC/Broker Information

/autoport