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Complete Home & Office Legal Guide
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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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1993-08-01
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680b
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28 lines
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:
______________________________________