Name on Payment Card or Account *

Card/Account Holder's Email Address *

Name of At Least One Client on the Attorney-Client Agreement *

Card/Account Holder's Relationship to the Client *SelectCorporation or LLC OwnerBusiness Partner or AssociateSpouse/PartnerOther FamilyOther Associate or Friend

Authorization *SelectThis is a one-time chargeThis card or account is to be used for all future billing charges by the Law Office for my services

Card/Account Holder's Email Address to Send Payment Authorization Form for Future Charges: *

Services Are For The Benefit of The Client *

• I understand the account holder will receive no direct benefit from this transaction or the legal services provided. I understand legal services provided to a business client are for the benefit of the business and not the individual owners, managers, or investors of the business.

On Behalf of the Client *

• I have read and fully understand the Law Office Third Party Payor Disclosure and Consent below. I agree that Attorney may accept compensation from Third Party Payor for my legal services under the terms and conditions of my Attorney-Client Agreement. I have been represented and advised by outside counsel in agreeing to this Disclosure and Consent or waive the right to such outside representation and advice. 

You should feel free to consult with independent counsel before consenting to this Third Party Payor Disclosure. Download a copy here https://fireduplawyer.com/ourservices/3rdpartydisclosure/. Do not submit payment if you do not consent on behalf of the Client.

Phone

Continue

Disclosure and Consent: Third Party Payor Payment of Attorney’s Fees and Costs

Under California Rules of Professional Conduct an attorney may not accept compensation from one who is not the client (Third Party Payor) without: (1) assuring the arrangement does not interfere with the attorney’s independence or professional judgment on behalf of the client or with the attorney-client relationship, (2) providing for protection of client confidential information and secrets, (3) providing the client with a written disclosure of the relevant circumstances and the actual and foreseeable adverse consequences arising from the arrangement, and (4) obtaining the client’s informed written consent.

The potential adverse consequences of having a Third Party Payor responsible for payment of attorney’s fees and costs is that the Third Party Payor may: (1) attempt to interfere with the attorney-client relationship between the attorney and client, (2) attempt to interfere with the attorney’s exercise of independent professional judgment on behalf of the client, (3) seek access to client confidential information or secrets contrary to the wishes of the client, or (4) use payment or withhold payment to attempt to influence attorney’s representation of the client.

Third Party Payor may not interfere with Attorney’s representation of the Client. Third Party Payor has no right to information regarding the representation. Attorney will not communicate with nor disclose any confidential or privileged information to Third Party Payor, unless the Client gives written permission to discuss some or all of their matter with Third Party Payor. Any disclosure must be subject to review by Attorney to protect Client’s right to expect full confidentiality.

Client, will remain responsible for and will pay Attorney’s bills in the event that Third Party Payor fails for any reason to pay invoices as they become due. If a refund is due at the conclusion of the representation, the refund will be paid to the person or entity who paid the fees and costs. All billing objections must be submitted by Client in accordance with the Attorney-Client Agreement. Objections submitted by Third Party Payor will not be accepted.

It is improper for attorneys to accept any payment or money from clients that they know or should know is derived from illegal sources. Client affirms and attests that all money paid to Attorney comes from a legal source.

Client should feel free to consult with independent counsel before consenting to this Third Party Payor Disclosure.