Legal Conflict Check Form

LEGAL CONFLICT CHECK FORM

This Legal Conflict Check Form is completed by and between Firm Name: and Client Name: with respect to the matter described below. Effective Date: .

RECITALS

WHEREAS, the Client seeks potential legal representation by the Firm in connection with a legal matter and requests the Firm to perform a conflicts check to identify any actual or potential conflicts of interest; and

WHEREAS, the Firm will conduct a reasonable search of its files, records and conflict databases and will rely on the disclosures provided by the Client in this Form to identify parties, related persons and previously represented entities that may create a conflict; and

WHEREAS, the parties wish to document the information necessary for the Firm to evaluate any conflicts and, where appropriate, to obtain any necessary waivers or provide a statement of non-representation.

NOW THEREFORE, in consideration of the mutual covenants and representations contained herein, the parties agree as follows.

1. DEFINITIONS

For purposes of this Form: "Firm" means the named law firm; "Client" means the named person or entity requesting representation; "Matter" means the legal matter described in Section 3; "Related Party" means any individual, corporate parent, subsidiary, affiliate, officer, director, trustee or other person or entity with a legal, beneficial or fiduciary relationship to the Client or any party identified in this Form.

2. CLIENT INFORMATION

3. MATTER DESCRIPTION

4. PARTIES, RELATED ENTITIES AND OPPOSING PARTIES

5. PRIOR REPRESENTATIONS AND MATERIAL FACTS

Has the Firm previously represented the Client, any Related Party, or any Opposing Party in any matter that may be relevant to the Matter? Yes No

6. CONFLICTS SEARCH AND RESULTS

Did the search identify any actual or potential conflicts of interest? Yes No

7. CLIENT REPRESENTATIONS AND AUTHORIZATIONS

The Client represents that the information provided in this Form is true, complete and accurate to the best of the Client's knowledge and that the Client will promptly notify the Firm in writing of any material changes. The Client authorizes the Firm to perform reasonable and customary conflict checks, including queries of internal and external databases, and to retain records of the results.

The Client requests (if applicable) a waiver of the disclosed conflict on the following basis:

8. CONFIDENTIALITY AND ATTORNEY-CLIENT PRIVILEGE

Information disclosed in this Form will be treated as confidential for the purposes of the Firm's conflict evaluation. Completion of this Form does not itself create an attorney-client relationship nor does it waive or alter existing privileges. The Firm will maintain confidentiality subject to applicable ethical rules and may withhold unrelated privileged information from the Client's disclosure.

9. LIMITATIONS, RELIANCE AND SCOPE

The Firm's conflict determination is based on the facts and parties disclosed by the Client and the Firm's available records at the time of the search. The Firm expressly disclaims responsibility for conflicts arising from undisclosed facts or parties, or from representations by other firms. This Form does not create an obligation to accept representation.

10. NOTICES

11. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Form shall be governed by and construed in accordance with the laws of the jurisdiction in which the Firm maintains its principal office. This Form constitutes the entire understanding between the parties concerning the conflict check and supersedes all prior discussions and representations with respect to the matters set forth herein. If any provision is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. AMENDMENTS, WAIVER, AND COUNTERPARTS

Any amendment to this Form must be in writing and signed by both parties. No failure or delay by either party in exercising any right will operate as a waiver except by a written waiver signed by the waiving party. This Form may be executed in counterparts, each of which will be deemed an original, and execution by electronic signature is acceptable.

13. CERTIFICATION

By signing below, the undersigned certify under penalty of perjury that they are authorized to provide the information and any requested waivers on behalf of their respective parties and that the statements contained in this Form are true and complete to the best of their knowledge.

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