Secure Disbursement Information

Please provide the information below so we can release your funds.
This page is secure and used solely for disbursement processing.

First Name

Last Name

Date of birth

Bank Name

Account Holder Name

Must match the name on your bank account

Routing Number

Account Number

Account Type

Checking

Savings

Government ID – Front *

Upload a clear photo of the FRONT of your government-issued ID.

Government ID – Back *

Upload a clear photo of the BACK of your government-issued ID.

Signature *

I certify that the disbursement information provided above is accurate and belongs to me.

I authorize Axis Capital LLC d/b/a CaseBridge Funding to disburse funds using the method selected.

I understand that incorrect or false information may delay or prevent funding.

Date Signed