[Southwest Viatical applicant cross reference checklist] Page: 3 of 26
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Southwest tical
2919Welborn Suite 102
Dallas, Texas 75219
(214) 559-4790
APPLICATION FOR A VIATICAL SETTLEMENT
The response that you provide on this form will enable SOUTHWEST
VIATICAL to determine if you are qualified for our program. Please fill
out this application as accurately as possible.
After you have completed the application, return with the Authorization
To Release Policy Information and the Authorization To Release Medical
Records forms to SOUTHWEST VIATICAL for consideration.
I. Personal Data (Please print or type):
A. Name :
B. Address
City : StateZip
C. Date of Birth State of Birth
D. Current County\State of Residence :
E. Social Security Number :
F. Telephone (Home) : ( )
(Work) : (_)
G. Next of Kin :
Relationship :
Address
City :.State Zip
Telephone : ( )
H. What are the names and ages of your spouse, children and grand
children?
I. Please list the name, address and telephone number of your
Attorney, C.P.A. or Financial Planner.
J. Please list any special situations or instructions for us to be
aware of in handling this application on your behalf.AVS-1/4
A
I
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[Southwest Viatical applicant cross reference checklist], legal document, 199X; (https://texashistory.unt.edu/ark:/67531/metadc916868/m1/3/: accessed August 15, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu.; crediting UNT Libraries Special Collections.