Fill and Sign the Disclosure Letter Form

Disclosure by Letter from Client to Attorney Regarding Division of Fees between Attorneys _____________________________________ Name of Client ____________________________________________________ Street Address or Post Office Box ________________________________________ City, State, Zip Code I, ______________________________________ (Name of Client) have been referred to the law office of _________________________________ ( name of attorney) , located at ______________________________________________________________________________ _______________________________________ (street address, city, county, state, zip code) , whose offices are at _____________________________________________________________ ________________________________________ (street address, city, county, state, zip code) . ______________________________________ (Name of referring attorney) has asked for the assistance of _______________________________ ( name of attorney to whom client referred) in prosecuting all claims arising from (describe) ______________________________________ ____________________________________________________________________________. __________________________________ (N ame of attorney to whom client referred) has informed me that he/she will be primarily responsible for the preparation and resolution of my claim. I understand, however, that _____________________________________ (n ame of attorney to whom client referred) will request assistance from ___________________________ (name of referring attorney) . I f urther understand that the participation of __________________________________ ( name of attorney to whom client referred) will not increase my fee, but that the attorneys will equally divide any fee that is obtained. I understand that both attorneys are responsible to see that my claim is properly handled and that this referral has been made in the hope of a more prompt and favorable resolution of my claim. By signing this document, I consent to the employment of __________________________________ (n ame of attorney to whom client referred) on the basis as set forth above. Dated: _______________________ _____________________________________ (Signature of Client) ______________________________________ (Signature of attorney to whom client referred)