Plaintiff Support Services
6400 Main Street, Suite 120
Williamsville, New York 14221
Toll Free: 1-800-352-9676
*indicates required field
The following application is for law firm post-settlement funding. Any fields marked with (*) are required fields.
Law firm name*
Date of birth
Social security number
Title of action*
ADDITIONAL APPLICATION INSTRUCTIONS
Include the following documents, if relevant to your case:
Submit to Plaintiff Support by email or fax:
Fax: (716) 639-8382
If you have any questions, please call 1-800-352-9676 to speak with a law firm funding specialist.
The following application is for attorneys applying on behalf of a client. Any fields marked with (*) are required fields.
Date of injury
Duration of injury
Disabled from injury?
Years at job
Funding amount requested
Funding via check or debit card?
Reason for funding request
Description of injury
Case type and description
Title of action (or provide any pleading)
Excess insurance policy limits
Are there any outstanding judgments or IRS tax liens against the applicant?
Has the applicant been or is the applicant currently involved in a bankruptcy or insolvency proceeding?
Has the applicant sought or received funds from any other funding company?
Law firm name*
Please provide a list of any and all liens, as well as the amounts of the liens that currently exist against any recovery the plaintiff may recieve:
There are no liens or other interests against the plaintiff's personal injury claimThe following liens exist (please select applicable below
Internal Revenue Service lienCompensationSSI / SSDWelfareRailroad Retirement BoardNo FaultMedical providers and / or other liens
If you have any questions, please call 1-800-352-9676 to speak with a plaintiff funding specialist.