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  • Name(Required)
  • What state is your case in?(Required)
  • Date of Accident(Required)
  • By providing your phone number on this application, you consent to receive autodialed informational phone calls to the number you provided to Relief Funding about the status of your application or related funding.
  • Address(Required)
  • Attorney Name(Required)
  • How should we contact you?(Required)
    If you check Text/SMS You authorize Relief Funding and its agents to call and text message me at the phone number provided in my application for information and marketing purposes using live operators and automated dialing systems. Message and data rates may apply. I understand my consent to receive autodialed marketing calls and text messages is not a condition of receiving funding.