Fill and Sign the Assignment Claim for Damages 497332906 Form

Assignment Claim for Damages For and in consideration of $       and other good and valuable consideration, receipt of which is acknowledged,       of (Name of Assignor)       , referred to herein as Assignor, assigns to (Street Address, City, County, State, Zip Code)       of       , referred to (Name of Assignee) (Street Address, City, County, State, Zip Code) herein as Assignee, all claims or causes of action that I have or may have against       , of       , or any (Name of Defendant) (Street Address, City, County, State, Zip Code) other person arising out of       . (Description of Basis of Claim) I appoint Assignee, Assignee's personal representatives and assigns, my true and lawful attorney- in-fact, irrevocably, with full power of substitution, for me and in my name, or otherwise, but for the sole use and benefit of Assignee, Assignee's personal representatives and assigns, to demand, sue for, compromise, collect, and give satisfaction such claims. Witness my signature this the       day of       , 20       . (Signature of Assignor)       (Printed Name of Assignor) Assignment Claim for Damages Page 1 of 1