By Submitting this form, I agree that all the information listed is accurate and correct. In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed without it.

I request and authorize my attorney to provide Impact Legal Funding with whatever information (whether oral or in writing) needed to evaluate my pre-settlement funding request. I specifically waive any privilege that I may have regarding such information. I hereby request and authorize your firm to cooperate with and release to Impact Legal Funding any and all information and documents pertaining to my case. Please share your candid opinion regarding this action with Impact Legal Funding, so that Impact Legal Funding can evaluate my funding request. I acknowledge that I understand the benefits and risks of non-recourse funding. I further acknowledge that I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges. Thank you in advance for your cooperation.

Records Release Authorization By clicking below, you indicate that you have read and agree to the Records Release Authorization. You must check this box for your application to be processed. This authorization gives us permission to contact your attorney and discuss your case with your attorney. We charge a $250 application fee, only for funding requests which we approve and only for cases in which we provide funding. The application fee is not due until you receive your settlement or award at the end of your case. If you lose your case, you owe us nothing.

By submitting this form I agree that all the information listed is accurate to the best of my knowledge.*