Fill and Sign the Fee Contingency Form

CONTRACT FOR LEGAL SERVICES I, _______________________, hereby retain and employ _______________________ , Esq., as my attorney to handle all proceedings of any kind, pursuant to the prosecution and recovery, or settlement of my claim regarding my injury which occurred while I was a patron at ________________, Inc. on the _______ day of ______________, 20____. I agree to pay said attorney's fees on the following basis: FIFTY (50%) PERCENT OF WHATEVER MAY BE RECOVERED FROM SAID CLAIM WHETHER BY SUIT, SETTLEMENT, OR IN ANY OTHER MANNER AFTER SUBTRACTING ALL EXPENSES INCURRED IN MAKING SUCH RECOVERY. I understand that _______________________ , Esq. reserves the right to withdraw from my representation, upon written notice to me, if after investigation of my claim it is determined that in his opinion my case does not merit further action. I agree that associate counsel may be employed at my discretion and expense of my attorney, and that any attorney so employed may be designated to appear on my behalf or undertake my representation in this matter. I further agree that in addition to the above attorney's fee, all court costs, subpoena costs, photographic costs, deposition and court reporter costs, medical record costs, expert witness costs, travel costs, and all other out-of-pocket expenses directly incurred in investigating or litigating this claim shall be paid by _______________________, Esq. or associated counsel, and that said expenses, interest on the same and attorney's fees will be deducted from the proceeds of any recovery from said claim before calculating the above stated attorney fees. - 1 - I give and grant unto _______________________ , Esq. full power to act as my attorney, to institute suit on said claim, to prosecute said suit, to settle said claim at his discretion before or after suit is initiated and to take any and all steps which he deems proper and desirable. If, on a trial, we win this case and the Defendant(s) take(s) an appeal, Plaintiff Attorney, Esq. is to be paid for services on appeal, an additional sum equal to the post-judgment interest on the primary award. I UNDERSTAND THAT THE ATTORNEY WILL CHARGE NO FEE FOR HIS SERVICES IF THERE IS NOT A RECOVERY IN MY CLAIM. ________________________ Client ________________________ DATE STATE OF ________________ COUNTY OF ______________ Personally appeared before me, the undersigned authority, a Notary Public in and for said State and County, _______________________, who is known to me and who being by me first duly sworn, on oath, deposes and says that, being informed of the contents of the instrument, he executed the same voluntarily on the day the same bears date. SUBSCRIBED and SWORN TO before me this _____ day of _______________, 20___. _______________________________________ NOTARY PUBLIC My Commission expires __________________. - 2 -