Wyo. Contingent Fee R. 6

Each contingent fee agreement shall contain the provisions of and be substantially in

the form of the agreement which follows these rules. Amendments of, or modifications

to, the provisions of paragraphs I through XI of the agreement, which effectively change

the rights of the client, shall have no force or effect unless such amendment or

modification is sanctioned by the Wyoming district court which does, or would have,

jurisdiction of the litigation.

Forms attached are as follows:

I. Representation Agreement

II. Authorization for the Release of Medical Information

III. Statement of Distribution — Gross Recovery

IV. Statement of Distribution — Net Recovery

(law firm letterhead optional)

REPRESENTATION AGREEMENT

to be executed in duplicate

Dated this...... day of.................................................................., (year)

ATTORNEY:

Address:

Phone:

CLIENT:

Address:

Phone:

CLAIM:

Date of occurrence:

Adverse party:

Event:

The client employs attorneys whose names are listed above to represent the client in

the handling, presentation and settlement of any and all claims which client may have

as a result of the event described above and to institute any and all litigation necessary

or advisable in the attorney’s sole discretion to resolve the client’s claim.

Associate counsel may be employed at the discretion and expense of the attorneys to

assist or principally prepare and conduct the trial of this matter. Sharing of employment and the terms of that employment shall be disclosed to the client.

No promise or representation has been made by said attorneys as to the outcome of

the claim or litigation, or as to what amounts, if any, the client may be entitled to

recover in this case.

I.

NEGOTIATION OF FEES

It is understood the amount of contingent fees are negotiated between the client and

the attorney. Different attorneys may charge differently for this matter. This fee is

intended to fairly compensate the attorney for the professional services rendered.

Factors considered in setting a contingent fee are:

1. The time and labor required;

2. The novelty and difficulty of the questions involved;

3. The skill requisite to perform the legal service required;

4. The forbearance of other work by the attorney;

5. The fee customarily charged in the locality for similar legal services;

6. The amount of costs incurred or advanced by the attorney in representing the

client;

7. The amount involved in the controversy and the benefits resulting to the client;

8. The time limitations imposed by the client or the circumstances;

9. The nature and length of the professional relationship with the client;

10. The experience, reputation, and ability of the attorney performing the services;

11. The contingency or certainty of the compensation;

12. Discussions with the defendant about settlement prior to counsel entering the

case.

II.

FEES

After discussion of the factors contained in the paragraph, Negotiation of Fees, the

client agrees to pay a fee in an amount set forth in paragraph (paragraph 1 or 2 must

be selected). If no recovery is obtained, no fee shall be payable to the attorneys. Gross

recovery is recovery before deducting costs. Net recovery is recovery after costs are

deducted. Costs are all litigation expenses incurred in the prosecution of the case other

than the attorney’s compensation.

SELECT PARAGRAPH 1 OR 2

PARAGRAPH 1 (FLAT PERCENTAGE)

The client agrees to pay a fee in an amount of.................................. percent

of the gross or net (delete one not applicable and if no exclusion, net fee applies)

recovery whether as a result of settlement or trial.

PARAGRAPH 2 (SCHEDULED PERCENTAGES)

The client agrees to pay a fee in the amount of................................. percent

of the gross or net (delete one not applicable and if no exclusion, net fee applies)

recovery if the claim is settled within sixty (60) days after filing suit. Thereafter, the fee

percentage shall be.................................................................... percent,

unless appeal is required, at which time a separate agreement for the fee percentage

shall be made.

Client and counsel have discussed whether any negotiations have been held regarding settlement before counsel entered the case. If there have been such discussions,

client shall furnish proof of any offer within seven (7) days of this contingent fee

contract. It is mutually understood that the status of any settlement negotiation has

been taken into account by the client and the attorney in reaching a contingent fee

arrangement.

III.

FEE DISPUTES

The client shall first contact his attorney with any questions concerning the charges

agreed to in this agreement. Any dispute or question that remains unresolved shall be

set forth in writing by both the attorney and the client and delivered to the other party.

If they do not agree on the resolution of the questions the client or the attorney shall

have this matter arbitrated by the Committee on the Resolution of Fee Disputes. The

Committee on the Resolution of Fee Disputes may be reached through the offices of the

Wyoming State Bar Association in Cheyenne, Wyoming. Thereafter the client or the

attorney may have recourse to the district court as provided by the Wyoming Supreme

Court Rules Governing Contingent Fees for Members of the Wyoming State Bar

(Wyoming Court Rules Annotated).

IV.

INVESTIGATION

The client understands the attorney will investigate the client’s claim. The attorney

may gather medical information, talk to witnesses, talk to family members, and take

such other actions as the attorney in his judgment deems necessary. The client agrees

to sign the attached Authorization for the Release of Medical Information to permit the

attorney to fairly investigate the client’s claim.

V.

EXPENSES

It is further understood and agreed the client shall pay all out-of-pocket costs

incurred in the prosecution of this claim, such as court costs, costs of litigation, travel

costs, expert witness fees, deposition expenses, and the like. It is understood these costs

may be in addition to the legal fees set forth above if a gross fee arrangement is made.

In the event such costs are not paid by the client currently, the attorney may advance

such costs and expenses which are to be reimbursed when billed and in no event later

than the conclusion of litigation whether or not a recovery is obtained.

Reimbursable costs shall be reported to the client on a regular basis.

VI.

MEDICAL EXPENSES

All medical expenses and medical charges of any kind for treatment of the client are

not included as litigation costs and are the responsibility of the client. In the event of

recovery, the client agrees the attorneys may pay any of these unpaid bills from client’s

share of the recovery. Should the client recover nothing, it is understood the attorneys

are not bound to pay any of these medical bills.

VII.

STRUCTURED SETTLEMENT

The attorney fees shall also be paid in a lump sum out of the initial payment by the

defendant unless otherwise agreed upon in the structured settlement agreement. The

attorney’s fees shall be based upon the present value of the structured settlement.

VIII.

STATEMENT UPON DISTRIBUTION

At the time of final distribution of the proceeds of the claim or litigation, the attorney

shall prepare and the client shall approve by signature, a final settlement accounting.

The Statement of Distribution shall include:

1. The source of funds.

2. The total amount of the recovery or settlement.

3. The contingency percentage.

4. The total costs.

5. The proceeds to the client.

6. The amount held in reserve, if any, for costs which have not yet been billed and a

statement of the period during which such reserve shall be held in trust.

7. Liens, if any, and the amount to be paid by the client.

Attached to this document is a form for use as the Statement of Distribution.

IX.

WITHDRAWAL OF ATTORNEY

The attorney, in his discretion, may withdraw at any time from the case by adequate

notice in writing: if the investigation discloses inability to collect damages, or discloses

no assets or liability of the defendant; or if the attorney determines the representation

is not compatible with directions; or if the conduct of the client is uncooperative.

X.

RESCISSION BY THE CLIENT

This agreement shall be effective immediately. However, the client shall have a

period of three (3) calendar days from the date hereon to rescind by notice in writing

postmarked by registered mail or actual delivery to the attorney before the end of the

third day.

XI.

RELEASE OF INFORMATION

The client authorizes the attorney to release any and all information including

doctors’ reports, medical reports, financial information, investigators’ reports, statements of witnesses, pictures, and other information, to the insurance company or such

legal representative of the defendant as the attorney may decide is appropriate for

settlement negotiations or as required by law in trial processes.

XII.

OTHER CONDITIONS

.......................................................................................................

.......................................................................................................

.......................................................................................................

.......................................................................................................

.............................................................

Dated this...... day of..............................................................., (year).

WE HAVE EACH READ THIS AGREEMENT BEFORE SIGNING

Attorney

Client(s)

....................................

.........................................................

BY: ...............................

.........................................................

Attachments:

Rules Governing Contingent Fees for Members of the Wyoming State Bar, Rules 5

and 6.

(law firm letterhead optional)

AUTHORIZATION FOR THE

RELEASE OF MEDICAL INFORMATION

ATTORNEY.......................................................................................

CLIENT/PATIENT...............................................................................

BIRTHDATE OF PATIENT.....................................................................

APPROXIMATE PERIOD OF TREATMENT................................................

To my health care providers:

You are hereby authorized and directed to furnish and release to my attorney or his

delegate all records and information which he may request and as he may separately

enumerate. My attorney or his delegate is permitted to examine, copy, or reproduce any

or all portions of my records. This release is intended to waive as to my attorney or his

delegate, physician-patient privilege which I may assert in regard to my diagnosis,

treatment and prognosis while in your care. You are to provide all records, billing,

x-rays, charts, and notes which my attorney may request regarding my past or present

mental, physical or dental condition, history, or treatment. You are further authorized

to consult with my attorney orally about my health care if he should so desire.

My attorney or his delegate is permitted to photograph my person, while I am present

in any hospital or health care provider.

All prior authorizations or releases are hereby cancelled. This authorization shall

continue until revoked by me in writing. A photostatic copy shall serve in the same

stead as an original.

............................................................

DATED

............................................................

PATIENT OR LEGAL REPRESENTATIVE

............................................................

RELATIONSHIP IF NOT PATIENT

............................................................

(law firm letterhead optional)

STATEMENT OF DISTRIBUTION

...................

(client name)

GROSS RECOVERY DISTRIBUTION

SOURCE OF FUNDS.......................

GROSS RECOVERY

(total funds)

$..........

LESS ATTORNEY FEES

(...% of $....)

..........

BALANCE AFTER ATTORNEY FEE

..........

LIENS

WORKER’S COMPENSATION

..........

(see attached)

OTHER LIENS

..........

UNPAID COSTS ADVANCED BY ATTORNEY

..........

(see attached)

BALANCE AFTER COSTS

..........

MEDICAL EXPENSES TO BE PAID

..........

(see attached)

BALANCE AFTER MEDICAL COSTS

..........

PROCEEDS DUE CLIENT

$..........

TRUST RESERVE FOR UNPAID COSTS

..........

BALANCE PAID HEREWITH

$..........

TOTAL FUNDS

..........

ACCEPTED AND APPROVED:

..........................

DATE....................

(CLIENT NAME)

..........................

(law firm letterhead optional)

STATEMENT OF DISTRIBUTION

.....................................

(client name)

NET RECOVERY DISTRIBUTION

SOURCE OF FUNDS.....................

GROSS RECOVERY

(total funds)

$..........

LESS COSTS INCURRED

..........

(see attached)

NET RECOVERY

$..........

ATTORNEY FEE AT........% OF $......

..........

PLUS COSTS ADVANCED BY ATTORNEY

..........

TOTAL PAYABLE TO ATTORNEY

..........

NET RECOVERY AFTER FEE

..........

PLUS COSTS ADVANCED BY CLIENT

..........

TOTAL PAYABLE TO CLIENT

$..........

LIENS

WORKER’S COMPENSATION

.......................

OTHERS

.......................

MEDICAL BILLS PAID

..........

(see attached)

TOTAL DEDUCTIONS

$..........

PROCEEDS DUE TO CLIENT

$..........

TRUST RESERVE FOR UNPAID COSTS

..........

BALANCE PAID HEREWITH

$..........

TOTAL FUNDS

..........

ACCEPTED AND APPROVED:

..........................

..........................

DATE....................

(ATTORNEY)