STRUCTURE BROKER'S AFFIDAVIT (NAME OF COURT) ---------------------------------------------------------------x (CASE CAPTION) ___________________________________an infant, by his/her Parent and Natural Guardian ___________________; and ___________________, individually, Docket No. ___________________ Plaintiffs, -against- STRUCTURE BROKER’S AFFIDAVIT Defendants. ----------------------------------------------------------------x UNDER THE PENALTIES FOR PERJURY, I ____________________________,of __________________________________, acting as structured settlement consultant in the above matter hereby warrant and represent, under oath, having first been duly sworn, the following facts to be true, complete and accurate to the best of my knowledge, information and belief: 1. No rebates, service fees, administrative fees, or other financial consideration of any kind or in any amount has been paid, will be paid or had been promised to be paid to any party, insurer, attorney, guardian or any other person, firm or corporation associated with this case by me or by my above stated company either directly or indirectly, by virtue of the structured settlement or otherwise, relating to this matter. 2. The cost to the defendant(s) and/or casualty insurer(s) of the structured settlement portion of the settlement in this case is $ _____________ inclusive of any applicable qualified assignment fee; and this cost to purchase the proposed annuity, was arrived at after a survey of the market of annuity providers in order to confirm and obtain the best value (price/quality) for the periodic payment plan now recommended. American LegalNet, Inc. www.FormsWorkflow.com 3. (Name of Defendant or Insurer) payments to (Name of Annuitant): will make the following future periodic [Provide full benefit payment schedule] 4. The obligation of (Name of Defendant or Insurer) to make the above future periodic payments will be assigned to _________________________, the Assignee. (Assignee) may fund the obligation assumed by the purchase of an annuity from (Insert name of annuity issuer) _________________________, an A.M. Best Company rated A+ or A++ insurer. A guarantee letter will be issued by (Insert name of guarantor) to guarantee the performance of said assignee. 5. The Annuity Issuer company above named, is licensed to issue insurance and annuity products in the State of New York. 6. The standard industry commission that we are receiving in this case is based on 4% of the (Insert name of annuity issuer) premium of $__________. This commission is paid by _________________________, the life insurer issuing the annuity policy. [If more than one broker is sharing in the commission, set forth the details supporting same]. 7. 8. The annuity being provided in this case is based upon guaranteed non-life contingent payments for the plaintiff, who is presently ______ years of age, having been born on ___________________. The annuity cost set forth in number two above reflects this nonlife contingent annuity cost; [Or] The life insurer(s) providing the annuity or annuities in this case has rated the plaintiff, who is presently ____ years of age, having been born on _________________, up to age ______ by reason of plaintiff’s medical condition. The annuity cost set forth in number two above reflects this rated age with regard to all life contingent annuity benefit payments Period certain only payments and guaranteed lump sum payments are not affected by rated age; [Or] By reason of said plaintiff’s non life impairing medical condition, the annuity being provided in this case is based upon a standard age quote for the plaintiff, who is presently years of age _________ having been born on ______________. The annuity cost set forth in number two above reflects this standard age rating. Period certain only payments and guaranteed lump sum payments are not affected by a rated age. Medical underwriting is inapplicable in guaranteed non-life contingent cases; [Or] No medical underwriting has taken place or will take place after the agreement to settle hasbeen reached without full disclosure to both plaintiff and defendant. No post settlement medical underwriting has or will take place to secretly reduce the defendant's cost. American LegalNet, Inc. www.FormsWorkflow.com 9. No present value calculations were provided in this case. All illustrations provided were based on actual cost only. 10. Neither I nor [company name] is an in-house broker of any party or casualty carrier involved in the settlement; nor am I or said company affiliated with or an “exclusive” broker of any of any party or casualty carrier involved in the settlement. _ without the express consent of the 11. Neither I nor [company name] will, ___________________________ plaintiff and the prior written approval of this court: _________________________________________ (a) provide any information about this settlement to any factoring company for any purpose; or (b) solicit the plaintiff or plaintiff's family on behalf of any factoring company for any purpose, including, but not limited to, the proposed sale of plaintiff's future periodic payments, nor will I or participate, assist, promote or aid in such solicitation by any person, firm, corporation or entity; or (c) seek or accept any consideration, financial or otherwise, directly or indirectly _____________________ from a factoring company. 12. The following documents have been annexed as exhibits to the application made to the court for approval of the recommended settlement proposal: Exhibit A Exhibit B Exhibit C Exhibit D Exhibit E - Proposed Settlement Agreement Proposed Assignment Agreement Proposed Annuity Contract Proposed Guaranty Agreement Rejected Alternative and/or Competing Proposals. THIS STRUCTURED SETTLEMENT AFFIDAVIT IS PROVIDED TO THE PARTIES TO THE SETTLEMENT WITHOUT COST AND WITH THE EXPRESS PURPOSE OF INDUCING THE PLAINTIFF(S), THE DEFENDANT(S), AND ALL PARTICIPATING INSURERS TO ENTER INTO AND/OR PARTICIPATE IN FUNDING THE STRUCTURED SETTLEMENT AGREED UPON IN THIS CASE. STATEMENTS SET FORTH HEREIN CONSTITUTE AFFIRMATIVE REPRESENTATIONS AND WARRANTIES BY THE UNDERSIGNED STRUCTURED SETTLEMENT CONSULTANT. ____________________________________ individually (Insert name of individual) and on behalf of [company name] Sworn on before me this ___________day of __________, 20__ Notary My Commission Expires: American LegalNet, Inc. www.FormsWorkflow.com