(Office Use Only) Date Received: ........................................ UCS 137-16 (01/17) Case Number: _________________ CONSENT TO FINAL AND BINDING ARBITRATION IN AN ARBITRAL FORUM OUTSIDE PART 137 UNDER 137.2 (d) OF THE RULES OF THE CHIEF ADMINISTRATOR [The language below may be incorporated into a retainer agreement between the parties] The parties to this agreement, ______________________________________ ("Client"), and _____________________________________________, Esq. ("Attorney"), agree that in the event a dispute should arise as to the attorney's fee for legal services, they will resolve the fee dispute by arbitration before an arbitral forum outside Part 137 of the Rules of the Chief Administrator of the Courts (22 NYCRR), and that the arbitration shall be governed by the rules and procedures of that forum. By signing this agreement, attorney and client acknowledge that they have received and read the official written rules, instructions and procedures for both Part 137 and the [LOCAL PROGRAM NAME] and the [ARBITRAL FORUM OUTSIDE PART 137 NAME] and the client has been advised: (1) that (s)he has the right to use the fee arbitration procedures of Part 137, and; (2) that (s)he is not required to agree to arbitrate this fee dispute in an arbitral forum outside Part 137. The client has also been advised of any fees associated with using the [ARBITRAL FORUM OUTSIDE PART 137 NAME]. By signing this form, Attorney and Client agree to waive their rights with regard to arbitration pursuant to Part 137, which includes the right to reject the arbitrator(s) award by commencing an action on the merits (trial de novo) in a court of law. ATTORNEY (Please print names below signatures) CLIENT Dated:_______________________ American LegalNet, Inc. www.FormsWorkFlow.com