Legal Information Release Acknowledgment

LEGAL INFORMATION RELEASE ACKNOWLEDGMENT

Client Name:   Client Address:

Recipient Name:   Recipient Address:

Effective Date:   Entity Type: Individual Organization

RECITALS

WHEREAS, Client Name: is the individual whose legal information and related records are the subject of this Authorization; and

WHEREAS, Recipient Name: requires access to certain legal information of the Client for a legitimate purpose described below; and

WHEREAS, Client voluntarily agrees to authorize the disclosure of specified legal information to Recipient on the terms and conditions set forth in this document.

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

1. AUTHORIZATION AND SCOPE

Client hereby authorizes any attorney, law firm, court, custodian of records, governmental body, or other third party in possession of Client's legal files or related information to disclose and deliver such information to Recipient, including but not limited to the categories of information indicated below. This authorization covers records and information created prior to, on, or after the Effective Date to the extent permitted by law.

Scope of information to be released (check applicable items):
Legal files and pleadings
Correspondence and communications
Billing records and invoices
Case notes, summaries and internal memoranda
Other (describe)

2. PURPOSE

The information released under this Authorization shall be used by Recipient solely for the following purpose(s):

3. DURATION AND REVOCATION

This Authorization shall remain in effect from the Effective Date until revoked by Client in writing. Revocation shall be effective only upon receipt by Recipient of written notice at the address set forth in the Notices section below and shall not affect disclosures made in reliance on this Authorization prior to Recipient's receipt of such revocation.

4. LIMITATIONS; CONFIDENTIALITY

Recipient shall not further disclose the information received hereunder except with Client's prior written consent or as required by law. Recipient shall use reasonable administrative, technical and physical safeguards to protect the confidentiality of the information and shall limit access to those individuals with a need to know for the stated purpose.

5. CONSIDERATION

The parties acknowledge that the mutual promises and covenants contained herein constitute sufficient consideration for this Authorization. Client further acknowledges that Recipient's reliance on this Authorization is a material inducement to Recipient's acceptance of the scope and purpose described herein.

6. INDEMNIFICATION AND RELEASE

Client releases and forever discharges Recipient and any disclosing third party from any and all liability, claims, causes of action or demands arising from or related to disclosures made pursuant to this Authorization, except to the extent such liability results from Recipient's willful misconduct or gross negligence. Client agrees to indemnify and hold Recipient harmless from any claims, liabilities, losses or expenses (including reasonable attorneys' fees) arising out of Client's breach of this Authorization or out of Recipient's reliance on the representations made by Client herein.

7. NOTICES

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Authorization shall be governed by and construed in accordance with the laws of the state specified by Client below, without regard to conflict of law principles. This document constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements, understandings and representations, whether oral or written. If any provision of this Authorization is held to be invalid, illegal or unenforceable in any jurisdiction, the remaining provisions shall remain in full force and effect.

Governing Law State:

9. AMENDMENT; WAIVER; COUNTERPARTS

This Authorization may be amended only by a written instrument executed by both parties. No failure or delay by any party in exercising any right under this Authorization shall operate as a waiver of that right. This Authorization 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.

10. REPRESENTATIONS AND CERTIFICATION

Client represents and warrants that Client is the person authorized to execute this Authorization, that Client has read and understands the terms and consequences of this Authorization, and that the information provided herein is true and correct. Client certifies that any third-party signatures or consents required to release information described herein have been obtained.

ADDITIONAL AUTHORIZATIONS

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