The State of（ ）（州名）

　　County of（ ）（县名） Know all men by these presents：

　　特此为证：

　　That I, ( ) have employed ( ) as my attorney to present me to prosecute¹ through settlement or judge certain claims I have and hold against ( ) and /or any all other persons, firms and corporations for or arising out of personal injuries to ( ) as well as damages to property caused by or growing out of a certain accident which occurred on or about the ( ) day ( ) of ( ) 20 ( ) .

　　我，╳╳╳，特聘请╳╳为我的律师，以代表我提起诉讼并通过调解或审判方式，就我在20╳╳年╳月╳日所发生的事故中所遭受的人身伤害及财产损失向╳╳、和/或其他任何和所有个人、商号和公司提出索赔。

　　I hereby full authorized² and empower my said attorney at law and also in my name, place and stead to bring suit on said claims or any of them, if necessary, and to prosecute the same to final judgement and to compromise and settle said claims or any of them with or without suit in any way or manner that he may deem beat or advisable, giving and granting also unto my said attorney full power to substitute one or more attorneys at law in his place or stead as my attorney in or concerning the premises³ or any part thereof or in the performance of any or all of the professional services hereunder whether in the trial or appellate court, such other attorneys of attorney to be paid by my above named attorney with no additional expense to me by way of attorneys‘ fees other than hereinafter set out.

　　在此，我正式授权我所指定的律师，以我的名义、地位和为维护我的利益，在必要时就上述所有或任何一项权利要求起诉；并委托他以他认为最恰当的方式，通过或不通过诉讼。以调解或审判方式，最终解决我所提出的所有或任何一项权利要求；我所指定的律师完全有权聘用一个或多个其他律师，以替代他自己在准备起诉或上诉过程中，就我提出是全部或任何一项权利要求，履行全部或部分法律职责；此种其他律师的费用应由我指定的律师承当，本合同所规定的应由我所支付的律师费用不得因此而增加。

　　In consideration of the services to be rendered to me by my said attorney hereunder, I hereby sell, transfer, assign and convey to my above named attorney or attorneys an undivided interest of ONE THIRD (1/3) interest in and to said claims and amounts received in settlement in the event same is or are settled without suit, and FORTY (40%) per cent of sane⁴ and of any judgement obtained or amounts received, on or for such claimed or suits, if same is or are collected by suit or by ───── settlement after suit is filed.

　　鉴于我所委托的律师按本合同为我提供的服务，在不经起诉而调解成功时，我将把三分之一（1/3）的索赔所得，或经起诉后再和解或判决时，把百分之四十（40%）的判决所得或其他所得款项之净利完全给予以上指定的律师或律师们。

　　No compromise of my said claimed may be made by said attorney without my consent.

　　未经本人同意，所委托律师不得就我提出的权利要求达成任何妥协。

　　WITNESS my hand this the ( ) day of ( ) 20 ( ).

　　本合同于20╳╳年╳月╳日签字，特此证明。

　　─────

　　（聘用人签名）