Legal Representation Rights Form

LEGAL REPRESENTATION RIGHTS FORM

This Legal Representation Rights Form is made and entered into as of the Effective Date: by and between Client Name: (hereinafter "Client"), and Representative Name: (hereinafter "Representative"). Client and Representative are each a "Party" and collectively the "Parties."

RECITALS

WHEREAS, Client desires to grant Representative certain rights to act on Client's behalf with respect to the matters and authorities described in this Form; and

WHEREAS, Representative represents and warrants that Representative is qualified and authorized to accept such appointment and to exercise the powers granted subject to the limitations set forth herein; and

WHEREAS, the Parties wish to set forth in writing the scope, duration, and limitations of the rights granted to Representative.

NOW, THEREFORE, in consideration of the mutual covenants and promises contained herein, the Parties agree as follows:

1. APPOINTMENT; SCOPE OF AUTHORITY

1.1 Appointment. Client hereby appoints Representative as Client's authorized representative to act on Client's behalf to the extent and for the purposes expressly set forth in this Form. Representative accepts such appointment and agrees to perform the duties described herein in good faith and in a manner consistent with applicable law.

1.2 Express Authorities. Representative is authorized, subject to the limitations below, to take the following actions on behalf of Client (check applicable boxes and describe any limitations in Section 1.3):

Appear and represent Client at hearings, meetings, and conferences

Receive and inspect Client records and communications related to the representation

Execute, sign, and deliver documents necessary to pursue, defend, or settle claims

Negotiate and agree to settlements and compromises on Client's behalf

1.3 Specific Limitations. If any limitation applies, state it below. If none, write "None."

2. CLIENT ACKNOWLEDGMENTS AND CONSENTS

2.1 Acknowledgment. Client certifies that Client is competent and has the authority to grant the rights set forth in this Form. Client acknowledges that Representative's exercise of the authority granted may affect Client's legal rights and obligations.

2.2 Confidentiality; Privilege. To the extent applicable, communications between Client and Representative shall be maintained in confidence. Client understands that certain communications may be protected by attorney-client privilege only if Representative is an attorney; otherwise privilege may not apply.

3. AUTHORIZATION TO OBTAIN INFORMATION

3.1 Representative is authorized to request and receive information, records, and documents from third parties reasonably necessary to carry out the scope described in this Form, including but not limited to medical, financial, and administrative records. Third parties may rely on this authorization until termination in writing as provided in Section 5.

4. LIMITATIONS AND PROHIBITED ACTIONS

4.1 Representative shall not, unless expressly authorized in writing by Client: (a) make gifts of Client property; (b) create or revoke a will or codicil on Client's behalf; or (c) execute powers of attorney on behalf of Client. Any exercise of authority beyond that expressly granted herein is void and not binding on Client.

5. TERM AND TERMINATION

5.1 Term. This Form becomes effective on the Effective Date specified above and remains in effect until terminated as provided below.

5.2 Termination. This Form may be terminated by either Party upon written notice to the other Party. Termination shall be effective upon receipt of such notice by the other Party or on a later date specified in the notice.

6. NOTICES

All notices, requests, consents, claims, demands, and other communications hereunder shall be in writing and shall be delivered to the addresses set forth below or such other address as either Party may designate by written notice to the other Party in accordance with this Section.

7. AMENDMENTS; WAIVER; COUNTERPARTS

7.1 Amendments. This Form may be amended or modified only by a written instrument signed by both Parties.

7.2 Waiver. No waiver of any breach or default hereunder shall be deemed to be a waiver of any subsequent breach or default.

7.3 Counterparts. This Form may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

8. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

8.1 Governing Law. This Form shall be governed by and construed in accordance with the laws of the jurisdiction specified by the Parties below, without regard to conflict of law principles.

8.2 Entire Agreement. This Form constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, understandings, negotiations and discussions, whether oral or written.

8.3 Severability. If any provision of this Form is held to be invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not be affected or impaired.

9. REPRESENTATIONS AND SIGNATURE CAPACITY

Each Party represents and warrants that the person signing this Form on its behalf is duly authorized to execute and deliver this Form and to bind the Party to the terms and conditions hereof. Each Party further certifies that the information provided herein is true, correct and complete to the best of that Party's knowledge.

Individual    Corporation    Limited Liability Company

Individual    Corporation    Limited Liability Company

Sign Now