Authority To Represent - Personal Injury

I understand that Roxanne Conlin & Associates, P.C. agrees to investigate the facts surrounding the following incident:

__________

in order to determine if the facts are sufficient to institute a claim against:

__________

In the event that Roxanne Conlin & Associates, P.C. determines that such facts are sufficient to pursue a claim, they agree to represent me and I agree to retain their services as attorneys under the following terms:

1. My attorneys will exercise their best efforts in my behalf and will not settle my case without my permission.

2. My attorneys will expect me to work on my case, to answer their calls and letters and supply them with complete and accurate information. My attorneys will also expect me to cooperate with them in all reasonable requests.

3. I will pay my attorneys 40% of any and all amounts recovered by settlement or trial or 45% on appeal or retrial; and I authorize my attorneys to deduct this amount from the proceeds recovered. In the event of settlement, attorney's fees may be negotiated separately. If a structured settlement is negotiated, attorney's fees will be based on 40% of the cost of the annuity or its present value, or if settled on appeal 45% or after a retrial is ordered then 45%.

4. My attorney will advance costs on my behalf. All costs advanced by my attorney will be repaid by me from my share. Costs include filing fees, depositions, experts, copying, travel expenses and the like.

Note: There may be other costs associated with the lawsuit but which are not considered to be costs of the lawsuit. Examples of that type of expense include such things as opening an estate, fees to tax advisors and all expenses for medical treatment.

5. At some point during the course of legal representation, a settlement proposal may arise which my attorney believes to be a just and reasonable resolution of my claim(s). Such a determination shall depend on my attorney's evaluation of the combination of the harm and financial losses suffered by me, the state of the applicable law, and the likelihood of prevailing at trial. If my attorney recommends a settlement proposal as just and reasonable and I refuse to accept said proposal, my attorney shall have the right to withdraw from my case and shall be entitled to the higher of the current hourly rate and all costs incurred to date or 40% of the last settlement offered.

6. I have the right to terminate my attorneys' services and this Agreement at any time. I will, however, still owe my attorneys any money due at the time I give attorneys notice of that decision. That will include advanced costs and the recoverable hourly rate already expended on my case. If my attorneys have negotiated a settlement which I do not wish to accept, I may owe them 40% of the amount negotiated in the event of recovery.

7. My attorneys have the right to withdraw from representing me if a) I insist upon pursuing an objective that is imprudent; b) I make representation unreasonably difficult or unethical; c) I fail to disclose information after being asked to do so or disclose false information; d) I fail to cooperate in pursuing my case; or e) other good cause for withdrawal exists. My attorneys do not give up their right to withdraw even where my attorneys continue to represent me after an event permitting withdrawal.

8. It is agreed that my attorneys have made no guarantees concerning the outcome in this matter.

9. I further authorize my attorneys to pay any medical bills or other bills from the proceeds before disbursing any proceeds to me.

10. IN THE EVENT OF NO RECOVERY, I SHALL OWE MY ATTORNEYS NOTHING FOR SERVICES RENDERED.

DATED at _________________________, Iowa, this _________ day of ___________, 2016.

_____________________________

ACCEPTED: _____ day of _______________, 2016.

By: _____________________________

Roxanne Barton Conlin