TO: (Enter Your Attorney's Name):

THIS WILL BE YOUR AUTHORIZATION TO PERMIT ADVANCE CASH AND SETTLEMENT FUNDING CORP. (ACSF), INCLUDING THEIR REPRESENTATIVES AND UNDERWRITERS,TO REVIEW MY COMPLETE FILE, AND/OR SECURE INFORMATION FROM YOU, IN CONNECTION WITH THE CLAIM OR LITIGATION WHICH YOU ARE NOW HANDLING FOR ME, FOR THE PURPOSE OF MY OBTAINING ADVANCE FUNDING.

I HAVE BEEN ADVISED THAT THERE MAY BE OTHER SOURCES FOR FUNDS THAT MAY HAVE MORE FAVORABLE RATES THAN ACSF, HOWEVER, BECAUSE I BELIEVE I DO NOT HAVE THE CAPABILITY TO ACCESS SUCH SOURCES, I HAVE DECIDED TO SEEK ADVANCE FUNDING THROUGH ACSF.

I UNDERSTAND THAT I MAY REVOKE THIS AUTHORIZATION AT ANY TIME. I FURTHER UNDERESTAND THAT IN ORDER TO REVOKE THIS AUTHORIZATION, I MUST DO SO IN WRITING (INCLUDING MY NAME, ADDRESS AND DATE OF BIRTH ) AND SEND MY REVOCATION TO A C S F, 4025 CATTTLEMEN RD., PMB 155, SARASOTA, FL, 34233. I ALSO UNDERSTAND THAT THE REVOCATION WILL NOT APPLY TO INFORMATION THAT HAS ALREADY BEEN RELEASED IN RESPONSE TO THIS AUTHORIZATION. ADDITIONALLY I UNDERSTAND THAT UNLESS OTHERWISE REVOKED, THIS AUTHORIZATION WILL EXPIRE UPON THE CONCLUSION OF MY CLAIM/CASE, WHETHER BY DISMISSAL, SETTLEMENT OR VERDICT.

I ALSO UNDERSTAND THAT BY GIVING THIS AUTHORIZATION, I MAY BE WAIVING THE ATTORNEY/CLIENT PRIVILEDGE AND FURTHER THAT BY GIVING THIS AUTHORIZATION I MAY BE MAKING DISCOVERABLE, BY THOSE AGAINST WHOM I AM MAKING A CLAIM, ANY MATERIAL PROVIDED TO ACSF.

A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE VALID AS THE ORIGINAL.

I UNDERSTAND THAT MY GIVING THIS AUTHORIZATION DOES NOT IN ANY WAY OBLIGATE ME TO ACSF, INCLUDING, THE SECURING OF AN ADVANCE FROM ACSF.

ENTER YOUR FULL NAME HERE:

ENTER YOUR E-MAIL ADDRESS HERE:

ENTER TODAY'S DATE HERE:  

I HAVE READ, UNDERSTOOD AND AGREED TO THE ABOVE AUTHORIZATION GIVING MY ATTORNEY PERMISSION TO RELEASE RECORDS AND INFORMATION PERTAINING TO MY CLAIM/CASE TO ACSF AND THAT THIS CAN BE CONSIDERED AS AN ELECTRONIC SIGNATURE.

YOU MUST CHECK "I AGREE" IN THE FOLLOWING SELECTION BOX TO HAVE YOUR APPLICATION PROCESSED.

I AGREE