Legal Settlement Disclosure

LEGAL SETTLEMENT DISCLOSURE

This Legal Settlement Disclosure (the "Disclosure") is made and entered into as of Effective Date: by and between Claimant Name: whose address is and Respondent Name: whose address is .

RECITALS

WHEREAS, Claimant commenced or threatened to commence legal action against Respondent under the matter described as: (the "Claim"); and

WHEREAS, the parties engaged in negotiations and exchanged information with the objective of resolving the Claim without protracted litigation; and

WHEREAS, the parties now wish to document the material terms of their settlement and to provide the disclosures required by applicable law concerning the allocation, tax treatment, and payment schedule of the settlement proceeds.

NOW, THEREFORE

In consideration of the mutual covenants and agreements set forth herein and other good and valuable consideration, receipt of which is hereby acknowledged, the parties agree as follows:

1. DEFINITIONS

For purposes of this Disclosure, the following definitions apply: "Settlement Amount" means the total gross amount to be paid by Respondent to Claimant as set forth in Section 2. "Net Proceeds" means Settlement Amount less amounts allocated to attorneys' fees, costs, statutory deductions, or other authorized offsets identified in Section 3.

2. SETTLEMENT AMOUNT AND PAYMENT SCHEDULE

Payment shall be made as follows (check applicable box and complete corresponding fields):

Lump sum payment due on or before:

Structured payments. Initial payment of due on , followed by periodic payments to total the Settlement Amount per the schedule:

3. ALLOCATION OF FUNDS

The parties hereby disclose their agreed allocation of the Settlement Amount among categories. Absent an express allocation below, Claimant acknowledges that Respondent may report the payment consistent with Respondent's reasonable interpretation of applicable law.

Parties acknowledge that tax treatment of each allocation may differ. Claimant is advised to seek tax counsel; Respondent disclaims giving tax advice. Any amounts withheld by Respondent for tax or statutory obligations shall be itemized and disclosed upon payment.

4. CONFIDENTIALITY AND PUBLIC STATEMENTS

The parties hereby declare the confidentiality status of this settlement. Select one:

Settlement and its terms are confidential. The parties shall not disclose the existence, amount, or terms of the settlement except as expressly permitted herein or required by law. Permitted disclosures:

Settlement is not confidential. Parties may make public statements as they reasonably determine.

5. RELEASES

Upon receipt by Claimant of the full Settlement Amount or the first scheduled structured payment as expressly provided, Claimant, on behalf of Claimant and Claimant's agents, heirs, executors, administrators, successors and assigns, fully and irrevocably releases and forever discharges Respondent, and its past, present and future affiliates, officers, directors, employees, agents, insurers and attorneys, from any and all claims, demands, liabilities, actions, causes of action, suits, debts, or obligations of any nature arising out of or relating to the Claim through the Effective Date, except for claims specifically reserved in writing below:

6. REPRESENTATIONS, WARRANTIES AND AUTHORITY

Each party represents and warrants that it has full authority to enter into this Disclosure and that its signatory is authorized to execute and deliver this Disclosure. Claimant represents that, to the best of Claimant's knowledge, there are no liens, subrogation, assignments, or other encumbrances affecting any portion of the Settlement Amount except as disclosed here:

7. TAX MATTERS

Claimant acknowledges that Claimant is solely responsible for all federal, state, local, and other taxes, penalties, and interest, if any, arising from or relating to any portion of the Settlement Amount, except to the extent a party expressly agrees in writing to withhold or report specific portions. Respondent makes no representations as to the tax consequences of any allocation and recommends Claimant consult independent tax counsel.

Will Respondent issue contemporaneous information reporting for amounts paid (if required by applicable law)? Yes No

8. LIENS, SUBROGATION AND THIRD-PARTY CLAIMS

If any third party asserts a lien or subrogation claim against the Settlement Amount, Claimant agrees to notify Respondent in writing within ten (10) days of receipt of such notice and to cooperate in resolving the claim. Claimant shall be responsible for satisfying or indemnifying Respondent against valid liens except as otherwise agreed in writing.

9. NOTICES

All notices required or permitted under this Disclosure shall be in writing and delivered by hand, reputable overnight courier, or certified mail, return receipt requested, to the addresses provided above and shall be effective upon delivery.

10. GOVERNING LAW; VENUE

This Disclosure shall be governed by and construed in accordance with the laws of the state selected by the parties: without regard to conflict of laws principles. Venue for any action to enforce this Disclosure shall lie exclusively in the courts located in the selected jurisdiction unless otherwise agreed in writing.

11. ENTIRE AGREEMENT; AMENDMENT; WAIVER; SEVERABILITY

This Disclosure, together with any executed settlement agreement and any exhibits attached hereto, constitutes the entire understanding between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements and understandings, whether oral or written. Any amendment to this Disclosure must be in a written instrument signed by both parties. No waiver of any provision of this Disclosure shall be effective unless in writing and signed by the waiving party. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

12. COUNTERPARTS; EXECUTION

This Disclosure 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 transmitted by facsimile or electronic image shall be effective as originals for all purposes.

13. ADDITIONAL TERMS

CERTIFICATIONS

Each party, by signing below, certifies under penalty of perjury that it has read and understands this Disclosure, that it has been afforded the opportunity to seek independent legal and tax advice, or has knowingly chosen not to, and that the representations made in this Disclosure are true and correct to the best of the signing party's knowledge.

Claimant represented by counsel? Yes No. If yes, Attorney Name:

Respondent represented by counsel? Yes No. If yes, Attorney Name:

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