Free Microsoft Word - TRANSFER OF STRUCTURED SETTLEMENT cover sheet2 - Rhode Island

COVER SHEET APPLICATION FOR COURT APPROVAL OF TRANSFER OF STRUCTURED SETTLEMENT PROCEEDS
Case Name: ________________________________ C.A. No.: _____________ Terms of Proposed Transfer: __________________________________________ Aggregate Amount of Purchased Payments: ______________________________ Discounted Present Value of Aggregate Payments: $ ______________________ at _________% interest Gross Amount Payable to Seller: $ ____________________________________ Itemization of Attorneys' Fees and Expenses to be Deducted from Purchase Price: Item: _______________________ Item: _______________________ Item: _______________________ Item: _______________________ Item: _______________________ Total: $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________ $ _______________________

Net Amount Payable to Seller: $ ______________________________________ Effective Annual Discount Rate: ______________% Net Amount = __________ % of Estimated Current Value of Payments Effective Interest Rate to be Paid by Seller: ___________%

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Original Personal Injury Case underlying Structured Settlement: C.A. No.: ___________________ Nature of Injury: _______________________________________________ Amount and Terms of Structured Settlement: ________________________ Purpose of Structured Settlement: _________________________________ Summary of Prior Applications for Court Approval of Transfer of Structured Settlement Proceeds (in Rhode Island and any other jurisdictions) including case number, terms of proposed transfer (see page 1 of this Cover Sheet), disposition (granted or denied) and date of disposition __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________

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