Application
for the sale of
Lottery Winnings


You can complete each page of this lottery application ONLINE.  If you
complete this application online, then Beneficial Brokers, LLC will be emailed
with your information.  If you choose to send your information online, then
please make sure that you sign and date at the bottom of the LAST page and
then fax it to Beneficial Brokers.

If you prefer, you can print ALL OF THE PAGES, sign and date at the bottom
of the LAST page, and then fax to Beneficial Brokers, LLC at 1-877-972-3847.

With either transmission method, your application will be faxed to Charter
Financial the SAME DAY or within 24 hours of receipt.
THANK YOU


 1. Date 

 2. Winner's name

 3. Address

 4. City 

 5. State

 6. Zip

 7. County or Parish

 8. Telephone

 9. Fax

10. Email

11a. Driver's license number      11b. State

12. Social security number

13a. Birth date     13b. Birth state  

Current Marital Status:
14. Single    

15. Married?   a. Yes     b. No

c. If yes, since

16a. Widowed     16b. Divorced

17. Have you been divorced or widowed since you won
the reward?  a. Yes     b. No

17c. If yes, then please provide your former spouse's name:


17d. Spouse's maiden name (if different)


 
    

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