Fill and Sign the Appendix T3 Form

Appendix T(3) Date Received By TRANSFEROR/SELLER: ___________, 200__ Disclosure Statement Pursuant to Chapter 20 of Title 12 of the Arizona Revised Statutes COMES NOW, the Transferee, ABC INVESTMENT, INC., and pursuant to Chapter 20 of Title 12 of the Arizona Statutes, as amended, hereby makes the following disclosures as required under the provisions of that section in connection with the above-captioned matter:(A) The amounts and due dates of the structured settlement payments to be transferred are:One (1) lump sum payment in the amount of $25,000.00 due on September 5, ______.One (1) lump sum payment in the amount of $35,000.00 due on September 5, ______.One (1) lump sum payment in the amount of $45,000.00 due on September 5, ______.One (1) lump sum payment in the amount of $55,000.00 due on September 5, ______.(B) The aggregate amount of these payments if $160,000.00;(C) The discounted present value of the payments, based upon an assumed discount rate of 5.0 percent (the Applicable Federal Rate) is $_____________;(D)The gross amount payable to Transferor/Seller), in exchange for transfer of these structural settlement payment rights is $___________;(E) The estimated fees and costs to be charged to Transferor, (Seller) with respect to this Transfer are:Brokers Fee:$ .00Attorney Fees:$ .00Filing Fees:$ .00Postage:$ .00Copies:$ .00TOTAL$ .00 (F)The net amount payable to Transferor/Seller following deduction of the aforementioned fees and expenses is $__________;(G)The quotient (expressed as a percentage) obtained by dividing the net payment amount by the discounted present value of these payments is _____; Therefore, the net amount that you will receive from us in exchange for your future Structured Settlement Payment Rights represents _____ percent of the estimated current value of the payments based upon the discounted value using the Applicable Federal Rate; and(H) The amount of any penalty and the aggregate amount of any liquidated damages (including penalties) payable by Transferor (Seller) in the event of your breach of the Transfer Agreement are:(1)Attorney’s Fees:$ .00(2)Rescission Fee:$ .00(3)Liquidated Damages:$ .00TOTAL:$ .00I have received and reviewed a copy of the foregoing Disclosure Statement. I agree with its terms, and my endorsement of this Statement reflects my understanding and acceptance of its Provisions. I am aware that I have three (3) business days from the date the Transfer Agreement is signed by me to change my mind about this transaction and if I wish to terminate the transaction without penalty I may do so within this said three (3) business day period by providing written notice to Buyer.Date: __________________ ____________________________Transferor (Seller)