STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT COVER SHEET FOR APPLICATION FOR COURT APPROVAL OF TRANSFER OF STRUCTURED SETTLEMENT PROCEEDS Plaintiff Civil Action File Number v. Defendant Terms of Proposed Transfer: Aggregate Amount of Purchased Payments: Discounted Present Value of Aggregate Payments: $ ______________________ at _________% interest Gross Amount Payable to Seller: Itemization of Attorneys' Fees and Expenses to be Deducted from Purchase Price: Item: _______________________________ $ _______________________ Item: _______________________________ $ _______________________ Item: _______________________________ $ _______________________ Item: _______________________________ $ _______________________ Item: _______________________________ $ _______________________ Total: $ _______________________ Net Amount Payable to Seller: $__________________ Effective Annual Discount Rate: _________% Net Amount = __________ % of Estimated Current Value of Payments Effective Interest Rate to be Paid by Seller: ___________% Original Personal Injury Case Underlying Structured Settlement: Civil Action File Number: ___________________ Nature of Injury: _______________________________________________ Amount and Terms of Structured Settlement: ________________________ Purpose of Structured Settlement: _________________________________ Superior-36 (revised October 2014) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS SUPERIOR COURT Summary of Prior Applications for Court Approval of Transfer of Structured Settlement Proceeds (in Rhode Island and any other jurisdictions) including case number, terms of proposed transfer (see page 1 of this Cover Sheet), disposition (granted or denied), and date of disposition. Has the Plaintiff previously filed an application(s) for Court Approval of Transfer of Structured Settlement Proceeds in this case? Yes No If "Yes," as to each, state the following: Date of Application _____________________ If granted, in whole or in part, the amount of proceeds transferred _________________________ If denied, in whole or in part, the date of the court Order ________________________________ Date of Application _____________________ If granted, in whole or in part, the amount of proceeds transferred _________________________ If denied, in whole or in part, the date of the court Order ________________________________ Date of Application _____________________ If granted, in whole or in part, the amount of proceeds transferred _________________________ If denied, in whole or in part, the date of the court Order ________________________________ Superior-36 (revised October 2014) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com