BY AND BETWEEN: __________________________________ AND: _________________________

1) I/We, ____________________________________, authorizes __________________________ to act as his/her agent for a fee.

2) _________________________________, certifies that he/she currently owns or retains title to, or has previously owned or retained title to:

3) ________________________________ shall execute any and all documents necessary for _________________________ to perform the service to obtain the government check in the amount of $____________.

4) _______________________________ shall pay to you __________________________ a fee in of the amount $________ for the services provided, within five (5) business days from the receipt of the $_________ unclaimed fund.

5) ____________________________________, understands that the $__________ government check should arrive at his/her mailing address in the form of a check, direct from the agency in possession of it, within 120 days of contact being made to the agency in possession of it, by the individual(s) entitled to this money.

6) Should suit be commenced or an attorney employed to enforce payment of the sum $________ pursuant this agreement

____________________________________ agrees to pay such additional sum as the court may adjudge reasonable as attorney's fees in said suit.

7) This agreement shall be governed by the laws of the state of ______________________.

By And Between: ____________________________________ 

And: _____________________________