“Based on the net amount that the payee will receive from this transaction ($)___ and the amounts and timing of the structured settlement payments that would be assigned, the payee is, in effect, paying interest at a rate of ___ % per year.”
(Caption)
Payee’s Affidavit in Support of Petition to Transfer Structured Settlement Rights
I, __________, the payee, verify that the statements below are true and correct:
______________________________________
_________________________
.
___
Never Married;
___
Married;
___
Separated;
___
Divorced
If married or separated, name of spouse:
____________
.
Initials of minor children, names of other dependents, ages, and places of residence:
__________________________________________________
__________________________________________________.
___
_________________________
.
_________________________
.
Obligation to pay:
___
Yes
___
No
If yes, state the amount of the obligation, to whom payable, and whether there are arrearages:
___
.
Have you previously filed a petition to transfer payment rights under the structured settlement that is the subject of this petition?
___
Yes
___
No
If yes, for each petition that you filed,
________________________________
_________________________
.
_________________________
.
_________________________
.
_________________________
.
Describe in detail your reasons for the proposed transfer, including an explanation as to why a sale of a lesser amount of the structured settlement amount will not better serve your interests: ______________________________________
_________________________
.
If you seek the transfer in order to pay debts, list each debt, including the name of the creditor and the amount presently owed:
Debt | Creditor | Amount Owed |
___ | ____________ | $ ___ |
___ | ____________ | $ ___ |
___ | ____________ | $ ___ |
Verification
I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities.
DATE:
____________
______________________________________
Signature
(CAPTION)
Initial Order of Court
On this
___
day of
____________
, 2
___
, it is ordered that a hearing on this Petition to Transfer Structured Settlement Payment Rights will be held on
___
, in Courtroom
___
at
___
o’clock. The payee shall bring income tax returns for the prior two (2) years to the hearing.
Within seven (7) days, the transferee shall give notice of the hearing date to the payee, the structured settlement obligor, the annuity issuer, the payee’s spouse and any person receiving child support, alimony, or alimony pendente lite. The transferee shall attach a certificate of service to the notice of hearing date. A copy of the notice with the certificate of service shall be filed with the court prior to the hearing.
BY THE COURT:
____________
J.
(CAPTION)
Notice of Hearing on Petition to
Transfer Structured Settlement Payment Rights
To: ______________________________________
You are hereby given notice that ______________________________________
(name of payee)
has filed a petition to transfer structured settlement payment rights. A hearing in this matter has been scheduled on
___
, 2
___
at
___
o’clock in courtroom no.
___
, courthouse,
_________________________
.
(address)
You are entitled to support, oppose or otherwise respond to the payee’s petition, either in person or by counsel, by filing written comments with the court prior to the hearing or by attending the hearing.
____________
______________________________________
Date Transferee
_________________________
_________________________
Address
_________________________
Telephone Number
(CAPTION)
Final Order of Court
On this
___
day of
____________
, 2
___
, it is ordered that the Petition to Transfer of Structured Settlement Payment Rights is granted.
The court specifically finds that:
________________________________
________________________________
.
___
, the amount of $
___
, from which no funds are owed for counsel fees, administrative fees, or other costs, fees or expenses.
BY THE COURT:
____________
J.
231 Pa. Code § 229.2