Legal Agency Disclosures Form

LEGAL AGENCY DISCLOSURES FORM

This Legal Agency Disclosures Form is made on , by and between Principal Name: Principal Address: and Agent Name: Agent Firm (if applicable): , Agent Address: .

RECITALS

WHEREAS, Principal seeks to engage Agent to act as Principal's agent with respect to legal services, negotiations, or transactions specifically described in this Agreement; and

WHEREAS, Agent is willing to accept such appointment subject to the disclosures, consents, and restrictions set forth below; and

WHEREAS, state and professional ethical rules require disclosure of certain agency relationships, potential conflicts of interest, referral arrangements and limits on authority, and the parties wish to record those disclosures and consents in writing.

NOW, THEREFORE, in consideration of the mutual covenants contained herein and other good and valuable consideration, the receipt and sufficiency of which are acknowledged, the parties agree as follows:

1. APPOINTMENT AND SCOPE OF AGENCY

1.1 Appointment. Principal hereby appoints Agent to act as Principal's legal agent for the purpose(s) set forth below, and Agent accepts such appointment subject to the terms of this Agreement.

2. NATURE OF RELATIONSHIP; TYPES OF AGENCY

2.1 Agent Relationship. Agent's role is limited to the scope expressly set forth. Agent shall act as an agent (including fiduciary duties where applicable) and shall not bind Principal except as expressly authorized in writing.

2.2 Election of Agency Type. The parties acknowledge the following representation type(s) (check all that apply):

3. DUTIES, DISCLOSURES AND CONFLICTS

3.1 Fiduciary Duties. Agent shall perform duties consistent with applicable law and professional standards, including confidentiality, loyalty, reasonable care, full disclosure of material facts, and obedience to lawful instructions.

3.2 Material Facts and Conflicts. Agent must disclose any material information or potential conflicts of interest known to Agent that reasonably could affect Principal's decisions in the matter. Principal acknowledges receipt of the disclosures checked below:

4. CONSENT TO DUAL OR LIMITED REPRESENTATION

4.1 Where Agent's representation may be limited or involve multiple parties with potentially divergent interests, Principal acknowledges that such representation may limit Agent's ability to advocate exclusively for Principal and expressly consents to the selected representation type above if applicable.

4.2 Waiver of Future Conflicts. Principal may not waive unknown future conflicts except to the extent permitted by applicable rules. Any waiver of a disclosed conflict must be explicit and in writing.

5. COMPENSATION, REFERRAL FEES AND THIRD-PARTY PAYMENTS

5.1 Compensation. Agent's compensation for services covered by this Agreement shall be as follows:

5.2 Referral Fees and Third-Party Payments. Agent shall disclose any referral fees, commissions, or third-party payments relating to the matter and shall not accept compensation from third parties that would materially affect Agent's duties without Principal's informed written consent.

6. CONFIDENTIALITY AND USE OF INFORMATION

6.1 Confidentiality. Agent shall maintain the confidentiality of Principal's information except as authorized in writing by Principal, required by law, or necessary to perform duties under this Agreement.

7. TERM AND TERMINATION

7.1 Term. This Agreement commences on the effective date above and continues until the earlier of completion of the scope of agency, written termination by either party, or the entry of a written agreement substituting representation.

7.2 Termination for Cause. Either party may terminate this Agreement for material breach, conflict of interest refusal, or failure to perform duties, subject to any applicable notice or cure periods.

8. NOTICES

8.1 Notices must be given in writing and delivered to the addresses below (or to updated addresses provided in writing). Notice is effective upon personal delivery, one business day after deposit with a nationally recognized overnight carrier, or three business days after posted by first-class mail.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

9.1 Governing Law. This Agreement shall be governed by and construed in accordance with the substantive laws of the state specified by the parties below, without regard to conflict of law principles.

Governing State:

9.2 Entire Agreement. This Agreement, together with any written exhibits or attachments executed by the parties, constitutes the entire agreement between the parties with respect to the subject matter and supersedes prior agreements, understandings, and representations, whether oral or written.

9.3 Severability. If any provision of this Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect, and the parties shall replace the invalid provision with a valid provision that most closely approximates the parties' intent.

10. AMENDMENT; WAIVER; COUNTERPARTS

10.1 Amendment. Any amendment or modification of this Agreement must be in writing signed by both parties.

10.2 Waiver. No waiver of any breach or default shall constitute a waiver of any subsequent breach or default.

10.3 Counterparts. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. CERTIFICATIONS AND ACKNOWLEDGMENTS

By signing below, Principal and Agent certify that they have read this Agreement, understand the agency relationships described, have had the opportunity to ask questions, and acknowledge receipt of the disclosures herein.

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