Attorney Agreement for Injury Collection

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Attorney Agreement for Injury Collection

I, _________________________, direct __________________________, to pay from the proceeds of any recovery related to or arising out of that incident occurring on _____________________ in which I was injured, such sums as may be due and owing to _______________________ for services which have been rendered or which will be rendered, up to a total amount of $_______________.

NOTICE: _________________________ is nevertheless liable for the fees due to _______________________ if no recovery is made.

It is understood that I shall retain all sums of money over the funds due ______________, which as referred to above, cannot exceed $ _____________.

Dated: _________________

______________________________________

_________________________ By Attorney

______________________________________

_________________________ By Injured Party

Witness:

______________________________________