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This will be your
authorization to permit Great Rock
Financial LLC, including their
representatives and underwriters, to
review my complete file, and/or
secure information from you, in
connection with the claim or
litigation which you are now
handling for me, for the purpose of
my obtaining advance funding.
I have been advised
that there may be other sources for
funds that may have more favorable
rates than Great Rock Financial LLC,
however, because I believe I do not
have the capability to access such
sources, I have decided to seek
advance funding through Great Rock
Financial LLC.
I understand that I
may revoke this authorization at any
time. I further understand that in
order to revoke this authorization,
I must do so in writing (including
my name, address and date of birth )
and send my revocation to Great Rock
Financial LLC, 19 Mulholland Drive,
Woodcliff Lake, NJ. I also
understand that the revocation will
not apply to information that has
already been released in response to
this authorization. Additionally I
understand that unless otherwise
revoked, this authorization will
expire upon the conclusion of my
claim/case, whether by dismissal,
settlement or verdict.
I also understand
that by giving this authorization, I
may be waiving the attorney/client
privilege and further that by giving
this authorization I may be making
discoverable, by those against whom
I am making a claim, any material
provided to Great Rock Financial
LLC.
A photocopy of this
authorization shall be valid as the
original.
I understand that my
giving this authorization does not
in any way obligate me to Great Rock
Financial LLC, including, the
securing of an advance from Great
Rock Financial LLC.
I have read,
understood and agreed to the above
authorization giving my attorney
permission to release records and
information pertaining to my
claim/case to Great Rock Financial
LLC and that this can be considered
as an electronic signature.
You must check "I agree" in the
following selection box to have your
application processed.
I agree
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