Rule 15-1303. Consent by Payee

A Consent by the payee shall be substantially in the following form. CONSENT TO PETITION FOR APPROVAL OF TRANSFER OF STRUCTURED SETTLEMENT PAYMENT RIGHTS Identifying Information [ ] I do not have an e-mail address. 5. [ ] I do not have a guardian of the person, guardian of the property, or representative payee. Employment [ ] I am not currently employed. Dependents 7. I am [ ] married [ ] divorced [ ] single. 8. I have [ ] __________ children under the age of 18 [ ] no children under the age of 18. 9. I am [ ] under an order of the _______________ (Name of court(s)) to pay a total of $ _____ per __________ (week/month) in spousal support [ ] not under a court order to pay spousal support. (Name of court(s)) to pay a total of $ ________ per __________ (week/month) in child support [ ] not under any court order to pay child support. Structured Settlement Agreement 11. In __________ (year): (Name of court). The case number is ___________________________________. [ ]a claim was made [ ] by me [ ] by my parent or guardian on my behalf. No court case was filed and the claim was settled without litigation. 12. I was represented in that case or claim by (Name of attorney). 13. In or as a result of that case or claim, I received a structured settlement pursuant to a structured settlement agreement. Independent Professional Advisor 14. I have selected ______________________________ as my independent professional advisor to explain the terms and consequences to me of the transfer and advise me regarding whether it is in my best interest to accept those terms, taking into account the welfare and support of my dependents. 15. My independent professional advisor has: [ ] met with me in person on __________ occasion(s); [ ] explained the terms and consequences of the proposed transfer agreement; [ ] answered all my questions; (Name of independent professional advisor) from: [ ] TV, radio, or other advertising [ ] Personal solicitation by the independent professional advisor [ ] Other: __________ (explain) 17 endents. 15. My independent professional advisor has: [ ] met with me in person on __________ occasion(s); [ ] explained the terms and consequences of the proposed transfer agreement; [ ] answered all my questions; (Name of independent professional advisor) from: [ ] TV, radio, or other advertising [ ] Personal solicitation by the independent professional advisor [ ] Other: __________ (explain) 17. [ ] I have not previously transferred any of my structured settlement payments. 18. [ ] I have made __________ previous transfers of some of my structured settlement payments and I have [ ] disclosed to my independent professional advisor the details of each such transfer and [ ] given to my independent professional advisor copies of the transfer agreements from each such transfer. 19. If the current transfer is approved, I intend to use the money that I receive for the following purposes: 20. After consultation with my independent professional advisor, I understand: [ ] that I am presently entitled to receive from my structured settlement $ __________ each [ ] month [ ] year; and that those payments will continue [ ] for the rest of my life or [ ] until __________, 20 _____. [ ] that I am entitled to receive lump sum payments due on the dates and in the amounts specified below: [ ] that the payments I now propose to transfer, in exchange for a net purchase price of $ __________, have a discounted present value of $ ____________________, as determined for federal tax purposes, and [ ] that the “effective annual interest rate” of the proposed transfer is __________ %. Based on the net amount that I will receive and the amounts and timing of the structured settlement payments that I am transferring, I will, in effect, be paying interest at a rate of __________ % per year so that I can get money now rather than later. 21. [ ] I have not received any advances or gifts of money, other property, or services in connection with the proposed assignment. 22 _________ %. Based on the net amount that I will receive and the amounts and timing of the structured settlement payments that I am transferring, I will, in effect, be paying interest at a rate of __________ % per year so that I can get money now rather than later. 21. [ ] I have not received any advances or gifts of money, other property, or services in connection with the proposed assignment. 22. [ ] I have received an advance or gift of ________________, from _____________________________________________ in connection with this assignment. 23. [ ] I have agreed to pay my independent professional advisor a fee of $ __________ for the services rendered by the advisor. My Understanding 24. I understand that, if the proposed transfer is approved: [ ] the discounted present value of the future payments that I would be transferring and would no longer be entitled to receive is $ ______________________________; and [ ] as consideration for the transfer, I would receive from the transferee the sum of $ ______________________________; which is __________ % of the discounted present value. [ ] From that sum, [ ] fees and other charges in the amount of $ __________ will be deducted or [ ] no fees or other charges will be deducted. 26. I have received a copy of the petition and [ ] have read it. Consent WITH THIS KNOWLEDGE, I HEREBY CONFIRM THAT I UNDERSTAND THE PROPOSED TRANSFER AND ITS CONSEQUENCES TO ME, AND I CONSENT TO THE PETITION. MY CONSENT IS VOLUNTARY. I HAVE NOT BEEN THREATENED WITH ANY LEGAL ACTION OR OTHER PENALTY IF I FAIL OR REFUSE TO FILE THIS CONSENT. Signature of Transferor Date Signature of Witness Date