(2) The full name, and age, of the Assignee must be stated. (3) The actual consideration for the assignment received from the assignee should be written in.For structured settlements, include: Structure settlement broker's affidavit;. Proposed settlement agreement;. If you are blind or seriously visually impaired and need this application in an alternative. To fill out this form, first gather all necessary personal and organizational information beforehand. 2. Complete Form VS-1, "Original Facility Application". Complete the application according to the instructions on the forms.