Legal Settlement Claim Form

LEGAL SETTLEMENT CLAIM FORM

This Legal Settlement Claim Form (the "Agreement") is entered into as of by and between Claimant Name: ("Claimant") and Settling Party Name: ("Settling Party").

RECITALS

WHEREAS, Claimant asserts that on or about an event or transaction occurred giving rise to claims described in Claim Number: ; and

WHEREAS, the Parties desire to fully and finally resolve and settle all disputes, claims, demands and causes of action that were or could have been asserted arising out of or related to the foregoing event without admission of liability; and

WHEREAS, the Parties agree that the terms and conditions set forth in this Agreement memorialize the settlement and the obligations of each Party in connection with payment, release, and confidentiality.

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

1. DEFINITIONS

For purposes of this Agreement, the following terms have the meanings set forth below: "Released Claims" means any and all claims, causes of action, suits, demands, obligations, damages, and liabilities, whether known or unknown, suspected or unsuspected, which Claimant has asserted or could have asserted arising out of the matters described in the Recitals.

2. SETTLEMENT PAYMENT

In full settlement of the Released Claims, Settling Party shall pay to Claimant the total gross amount of (the "Settlement Amount") according to the payment terms set forth below.

3. RELEASE

Upon full payment of the Settlement Amount in accordance with Section 2, Claimant, on behalf of Claimant and Claimant's heirs, executors, administrators, successors and assigns, irrevocably and unconditionally releases and forever discharges Settling Party and its past and present officers, directors, employees, agents, insurers, attorneys, successors and assigns from all Released Claims arising out of the facts and circumstances described in the Recitals.

4. REPRESENTATIONS AND WARRANTIES

Claimant represents and warrants that Claimant has the full right, power and authority to execute and deliver this Agreement and to perform its obligations hereunder; that no other person or entity has an interest in the Released Claims that would impair the effectiveness of this release; and that Claimant has not assigned, transferred or encumbered any of the Released Claims.

5. CONFIDENTIALITY

Except as otherwise required by law, the Parties shall keep confidential the terms and amount of this Agreement and shall not disclose such information to any third party without the prior written consent of the other Party, except to the extent disclosure is necessary to effectuate payment, to obtain legal or tax advice, or to comply with a legal obligation.

6. TAX MATTERS

Each Party shall be responsible for its own tax reporting and payment obligations arising from the Settlement Amount. If withholding is required by applicable law, Settling Party may withhold the required amount and shall provide Claimant with reasonable documentation of such withholding.

7. NOTICES

All notices or communications required or permitted under this Agreement shall be in writing and delivered to the addresses set forth below. Notices shall be deemed given when delivered by hand, by nationally recognized overnight courier, or by certified mail, return receipt requested.

8. AMENDMENTS; WAIVER

This Agreement may be amended or modified only by a written instrument signed by both Parties. No waiver of any provision shall be effective unless in writing and signed by the Party against whom enforcement is sought. No failure or delay in exercising any right shall operate as a waiver.

9. GOVERNING LAW

This Agreement shall be governed by and construed in accordance with the laws of the state indicated below, without regard to its conflicts of law principles.

10. ENTIRE AGREEMENT; SEVERABILITY

This Agreement constitutes the entire agreement between the Parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether written or oral. If any provision of this Agreement is held invalid or unenforceable, such provision shall be severed and the remainder of the Agreement shall remain in full force and effect.

11. COUNTERPARTS

This Agreement 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. Signatures provided by electronic means that reproduce a handwritten signature shall be deemed original signatures for all purposes.

12. ACKNOWLEDGMENTS

Claimant acknowledges that Claimant has read this Agreement, fully understands its terms, and has had the opportunity to obtain independent legal and tax advice prior to execution. Claimant further acknowledges that the Settlement Amount is fair and adequate consideration for the release of the Released Claims.

13. CERTIFICATION

By signing below, each signatory certifies under penalty of perjury that such signatory is authorized to execute this Agreement on behalf of the Party identified, that the information provided in this form is true and correct to the best of such signatory's knowledge, and that the obligations set forth herein are binding.

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