CONTINGENT FEE AGREEMENT

NAME__________________________________ SS# __________________________
_______________________________________ TEL. NO. (H)___________________
ADDRESS______________________________ TEL. NO. (W)___________________
CITY __________________________________ STATE______ ZIP______________
I (We) constitute and appoint the law firm of DESSEN, MOSES & ROSSITTO as my (our) attorney to investigate/prosecute a claim for _______________________________________________________
________________________________________________(Type of Action)
against _________________________________________________________
(Names of Defendants)
The Claimant (deceased) is ______________________________ and the cause of action
arose on ____________________________________.
(Date) 1. I/We hereby agree that the compensation of my/our attorneys for services shall be as follows: _________ percent ( %) of the gross amount of any recovery by way of settlement, arbitration and/or trial, and/or from any source of collateral coverage, (e.g., uninsured motorist coverage, underinsured motorist coverage, etc.) and they shall further be entitled to reimbursement of any and all expenses made by DESSEN, MOSES & ROSSITTO in connection with the institution and processing of my/our claim, (eg., Prothonotary and court fees, investigation expenses, witness and expert witness fees, costs of duplication for briefs, notes of testimony and/or transcripts, etc.).

2. I/We hereby agree that DESSEN, MOSES & ROSSITTO is authorized to pay from my/our remaining share of the gross recovery any and all unpaid medical bills.

3. If there is no recovery on my behalf, I/we will be responsible only for the reasonable and necessary costs incurred by DESSEN, MOSES & ROSSITTO in the investigation and prosecution of my/our claim.

4. I/We acknowledge that my/our attorneys have advised me/us that the relationship of attorney and client is based upon mutual trust and confidence and that they will endeavor to keep me/us advised of important developments in their representation of me/us. They have further advised me/us that I/we are free to communicate with them and ask them questions from time to time as appropriate.

5. It is further understood and agreed that upon their notification to me/us by Certified or Regular U.S. Mail, said attorneys may withdraw as counsel in the event of my/our failure to cooperate or If they conclude in their sole judgment that the claim cannot be successfully prosecuted by them. In the event the attorneys withdraw as my/our counsel, they agree that I/we will not be obligated to pay them legal fees for any professional services they have rendered.

6. I/We further agree that should I/we discharge said attorneys, I/we shall be liable to pay them the fair value of all services rendered by them prior to the receipt of a written notice of discharge. I/we further agree that if I/we discharge said attorneys, I/we shall reimburse them for all expenditures they have made in furtherance of the investigation and prosecution of the claim. I/we agree that the attorneys may retain possession of all documents and papers of every kind that they have until they are paid and/or arrangements acceptable to said attorneys for payment are made.

7. I/We hereby acknowledge that a copy of this document has been given to me/us and that It we have been advised to retain it in my/our possession. I/we further acknowledge that I/we have read and understood the contents of the document before I/we have signed it.

CLIENT:___________________________ DESSEN, MOSES & ROSSITTO

CLIENT:___________________________ By:________________________________

DATE: ____________________________

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