Legal Conflict Disclosure Statement

LEGAL CONFLICT DISCLOSURE STATEMENT

This Legal Conflict Disclosure Statement (the "Statement") is made as of by and between Firm Name: with principal address: and Client Name: , whose address is:

Recitals

WHEREAS, Firm represents that it has conducted a reasonable conflicts check and has identified certain relationships and matters that could reasonably be perceived to create a potential conflict of interest with respect to the representation of Client; and

WHEREAS, Firm has disclosed in good faith the known relationships and matters described in this Statement and seeks Client's informed consent to continue or commence representation subject to the terms set forth herein; and

WHEREAS, Client desires to understand the nature of any identified or potential conflicts and to provide any consent or direction required by applicable rules of professional conduct.

NOW THEREFORE, in consideration of the mutual promises contained herein and other good and valuable consideration, the parties agree as follows:

1. Definitions

For purposes of this Statement, "Firm" means the law firm identified above and any partner, associate, of counsel, or other professional employed by or affiliated with that firm; "Client" means the named client and any related entity specifically identified in writing; "Matter" means the legal matter or representation described below.

2. Description of the Matter

3. Disclosed Relationships and Conflicts

Firm discloses the following existing or reasonably foreseeable relationships, representations, interests or matters that may constitute a potential or actual conflict of interest with respect to the Matter. The disclosure below identifies the party or matter, the nature of the relationship, and any measures proposed or in place to mitigate the potential conflict.

4. Proposed Safeguards and Screening Measures

To address the identified conflict(s), Firm proposes the following safeguards, which may include but are not limited to: ethical screens, restricted access to files and communications, separate fee arrangements, or withdrawal from representation where required by applicable rules. The effectiveness of these measures is subject to Client approval and the requirements of governing professional conduct rules.

5. Client Acknowledgment and Informed Consent

Client acknowledges receipt of the disclosures above, affirms that the disclosures are accurate to the best of Client's knowledge, and provides informed consent to Firm's continued or prospective representation in the Matter subject to the safeguards set forth in this Statement and any additional conditions set forth herein.

I, the Client, acknowledge and consent to the disclosures and the safeguards described above.

6. Future Conflicts and Duty to Update

Firm will continue to perform conflicts checks and will advise Client promptly if additional information arises that may create a conflict. Client agrees to notify Firm of any relevant facts or circumstances known to Client that could reasonably be expected to affect the conflict analysis. If new conflicts arise that cannot be adequately cured by safeguards, Firm may be required to withdraw from representation.

7. Confidentiality and Use of Information

Firm's obligations of confidentiality are governed by applicable rules of professional conduct and by the attorney-client relationship. Notwithstanding such obligations, Firm may disclose the existence of its relationship with Client or the identity of the Client to the extent necessary to comply with conflicts-checking procedures, internal recordkeeping, ethical screens, or as otherwise required by law. Any such disclosure will be limited to the minimum information necessary.

8. Remedies and Limitations

If Client later revokes consent with respect to a disclosed conflict or if Firm determines that continued representation is untenable under governing professional rules, Firm may withdraw from representation upon reasonable notice. Client understands that consent does not guarantee that third parties or tribunals will accept the waiver of a conflict and that adverse rulings may affect Firm's ability to represent Client.

9. Notices

Any notice required or permitted under this Statement shall be in writing and delivered to the addresses set forth below or to such other address as either party may designate in writing. Notices shall be effective upon personal delivery, or three business days after deposit in the mail with first-class postage prepaid.

10. Governing Law

This Statement shall be governed by and construed in accordance with the laws of the state selected by the parties below, without regard to conflicts of law principles that would apply the laws of another jurisdiction.

11. Entire Agreement; Severability

This Statement contains the entire agreement between the parties with respect to the subjects addressed herein and supersedes all prior oral or written statements or agreements. If any provision of this Statement is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. Amendments; Waiver; Counterparts

No amendment, modification or waiver of any provision of this Statement shall be effective unless made in writing and signed by both parties. Waiver of any breach shall not constitute waiver of any other or subsequent breach. This Statement may be executed in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument.

13. Certification

Each signatory below certifies under penalty of perjury that he or she is authorized to execute this Statement on behalf of the party identified and that the facts and disclosures set forth herein are true and correct to the best of the signatory's knowledge.

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