The State of（ ）（州名）
County of（ ）（县名） Know all men by these presents：
That I, ( ) have employed ( ) as my attorney to present me to prosecute through settlement or judge certain claims I have and hold against ( ) and /or any all other persons, firms and corporations for or arising out of personal injuries to ( ) as well as damages to property caused by or growing out of a certain accident which occurred on or about the ( ) day ( ) of ( ) 20 ( ) .
I hereby full authorized and empower my said attorney at law and also in my name, place and stead to bring suit on said claims or any of them, if necessary, and to prosecute the same to final judgement and to compromise and settle said claims or any of them with or without suit in any way or manner that he may deem beat or advisable, giving and granting also unto my said attorney full power to substitute one or more attorneys at law in his place or stead as my attorney in or concerning the premises or any part thereof or in the performance of any or all of the professional services hereunder whether in the trial or appellate court, such other attorneys of attorney to be paid by my above named attorney with no additional expense to me by way of attorneys‘ fees other than hereinafter set out.
In consideration of the services to be rendered to me by my said attorney hereunder, I hereby sell, transfer, assign and convey to my above named attorney or attorneys an undivided interest of ONE THIRD (1/3) interest in and to said claims and amounts received in settlement in the event same is or are settled without suit, and FORTY (40%) per cent of sane and of any judgement obtained or amounts received, on or for such claimed or suits, if same is or are collected by suit or by ───── settlement after suit is filed.
No compromise of my said claimed may be made by said attorney without my consent.
WITNESS my hand this the ( ) day of ( ) 20 ( ).