Legal Settlement Breakdown Form

Legal Settlement Breakdown Form

This Legal Settlement Breakdown Form (the Agreement) is entered into as of Settlement Date: by and between Plaintiff Name: with Plaintiff Address: and Defendant Name: with Defendant Address: .

Recitals

WHEREAS, Plaintiff asserts certain claims against Defendant arising out of the events and circumstances described in the pleadings and related case materials; and

WHEREAS, the Parties desire to compromise and settle all disputes between them on the terms set forth herein to avoid further litigation, expense and uncertainty; and

WHEREAS, the Parties require a written allocation and disbursement plan to govern the handling of settlement funds, payment of liens, taxes, costs and attorneys' fees.

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

1. Definitions

For purposes of this Agreement, the following terms shall have the meanings set forth below: "Settlement Funds" means the total gross amount to be paid by or on behalf of Defendant to resolve the Claims; "Net Recovery" means Settlement Funds remaining after payment of attorneys' fees, costs, liens, taxes and other agreed deductions; "Claims" means all known and unknown claims released herein.

2. Settlement Amount and Allocation

The Parties agree the gross Settlement Funds shall be:

The Parties direct the allocation of Settlement Funds as follows (each item to be paid from the gross Settlement Funds):

3. Disbursement Procedures

Defendant shall cause Settlement Funds to be delivered by wire, check or other agreed instrument to the designated payee within the time period set forth below. Unless otherwise agreed in writing, disbursement shall occur no later than days following receipt by the payee of the full gross Settlement Funds.

Settlement Funds will be held by:

Funds handling selection: Counsel to hold funds Escrow agent to hold funds

4. Liens, Withholdings and Taxes

All known medical liens, statutory liens, wage garnishments, tax withholdings and other encumbrances that attach to the Settlement Funds shall be satisfied from the gross Settlement Funds as provided in the itemized breakdown. Each Party shall cooperate in executing documents necessary to effectuate payment of such liens in accordance with applicable law.

The Parties acknowledge that responsibility for payment of income taxes arising from the Settlement Funds shall rest with the recipient of the net proceeds unless otherwise required by law. Each recipient agrees to indemnify the other for taxes resulting from that recipient's failure to report or remit taxes.

5. Attorneys' Fees and Costs

Attorneys' fees shall be paid as follows: Fee Arrangement (select one or describe):

Contingency Fee Percentage: %

6. Release

Upon disbursement of the Net Amount to Plaintiff in accordance with this Agreement, Plaintiff, on behalf of Plaintiff and Plaintiff's heirs, executors, administrators, agents and assigns, fully and forever releases Defendant, Defendant's insurers, agents, employees and attorneys from all claims, demands, causes of action and liabilities of every kind and nature, known or unknown, arising out of the facts alleged in the underlying matter.

7. Representations and Warranties

Each Party represents and warrants that it has the full power and authority to enter into this Agreement; that the person signing on behalf of any corporate or organizational Party is authorized to bind that entity; and that no consent of any third party is required to effectuate the terms hereof except as disclosed in writing to the other Party.

8. Confidentiality

The Parties agree that the terms, amounts and circumstances of this settlement shall be confidential and shall not be disclosed to any third party except as required by law or as necessary to effectuate the terms of this Agreement. Disclosure to tax authorities, insurers, counsel or as required by court order shall not constitute a breach.

9. Notices

All notices required or permitted under this Agreement shall be in writing and shall be deemed given when delivered personally, sent by certified mail, return receipt requested, or by nationally recognized overnight courier to the addresses listed above.

10. Amendments; Waiver; Counterparts

This Agreement may only be amended by a written instrument signed by both Parties. No waiver of any provision shall be effective unless in writing and signed by the waiving Party. This Agreement may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

11. Governing Law; Entire Agreement; Severability

This Agreement shall be governed by and construed in accordance with the substantive laws of the state specified by the Parties: Governing State:

This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior negotiations, understandings and agreements. If any provision of this Agreement is held to be invalid or unenforceable, the remaining provisions shall continue in full force and effect.

12. Authority to Execute and Certification

Each signatory below certifies that they have read this Agreement, that they understand its terms and that they have the authority to bind the Party on whose behalf they sign. Each signatory further certifies that no other person or entity has any interest in the proceeds except as disclosed herein.

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