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. 

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

Dated: _________________ 




______________________________________ 
_________________________ 

Witness:  



______________________________________