CLIENT Acknowledgment FORM

CLIENT Acknowledgment FORM

I have been advised by representatives of the(“Law Firm”) that I have options concerning how to receive my settlement proceeds. I was advised that Law Firm does not give tax or financial advice, and I was advised to secure financial advice from a professional competent to render advice about settlement options. I was particularly advised to seek advice concerning structured settlement annuities, structured settlement trusts, government entitlements, special needs trusts, and the tax issues involved in receiving settlement proceeds.

I was provided written information about the above issues prepared by , and was given an opportunity to meet with them to develop a personalized “settlement plan” at no charge to me. This plan would provide tax, financial planning, government entitlement and settlement planning advice that would help me make appropriate decisions.

Check the Appropriate Sentence Below:

______I met with Edward C. LeCarpentier III, J.D., CSSC of Lawyers Insurance Agencyto discuss the above issues, especially as they relate to the use of structured settlements and other settlement planning issues, on . I had the opportunity at that meeting to discuss all of these options, however, I have decided to receive my settlement proceeds in cash.

______I also met with ______, a North Carolina estates and trust attorney, concerning the use of Special Needs Trusts, Settlement Preservation Trusts and other available trusts in order to prevent premature dissipation of my settlement funds and avoid the loss of certain governmental entitlements, and have decided to receive my settlement proceeds in cash.

I have discussed and understand to my satisfaction each of the following: (Please read and initial each)

Decision is Irrevocable.

Once I receive my settlement, I will never have a chance to obtain a structured settlement with it.

Tax Free.

Structured settlement payments including interest would have been excluded from income tax.

Creditor Protection.

A structured settlement receives statutory protection from the claims of creditors and to some extent the claims of present and future spouses.

Rated Age.

I may have qualified for a “rated age” which could substantially increase my lifetime annuity payout.

Government Entitlements.

Taking cash may affect my eligibility for certain government entitlement programs.

Guaranteed Lifetime Income.

A structured settlement could provide me with lifetime income guaranteed by a highly-rated life insurance company.

Estate Taxes.

There may be estate tax implications of receiving this settlement in cash.

Dissipation Protection.

Many personal injury victims dissipate or lose a substantial part of their recoveries. A structured settlement places contractual and statutory restrictions on my access to the funds making them more difficult to dissipate.

By initialing the paragraphs above I acknowledge that Law Firm made every effort to ensure I was adequately informed about my settlement options and the impact my decisions might have on my future.

______

Client Name

______

Date

______

Settlement Planner

______

Date