DAR-LIENS, INC. - Phoenix, Arizona's Premier Lien Service

The undersigned hereby authorizes Dar-Liens, Inc. to act as my/our Limited Agent in preparation and service of Health Care Provider Liens and Releases, to protect my/our Lien entitlements under the laws of the State of Arizona. (ARS 33-931-ET SEQ).

We the undersigned agree that Dar-Liens, Inc. will prepare Liens and Releases and bill me/us. (Please check one.)

(1)		As Liens and Releases are prepared on a daily basis.
(2)		On a monthly basis, with a list of names of each case liened or released in that given month.

(1)
If I/we choose to be billed on a daily basis, payments are due by the last day of the month billed. I/we agree to have payments into Dar-Liens, Inc. office no later than the last day of each month. If payment is not in by the last day of each month there will be a two percent (2%) late fee assessed to my/our account at the beginning of the next month.

(2)
If I/we choose to be billed on a monthly basis, payments are due in full by the fifteenth (15th) day following the date on the monthly invoice. If payment is not received by Dar-Liens, Inc. by the fifteenth (15th) day of the following month, there will be a monthly late fee of two percent (2%) assessed to the account.

Any balance that exceeds 60 days will be put on C.O.D. status until my/our account is paid in full. We agree to pay all fees incurred to collect my/our delinquent account, the cost of which will be added to my/our account balance. This is an exclusive contract for a period of one year renewable each year on the anniversary date of the first signing of the contract.

This contract forbids me/us from using Dar-Liens, Inc. "Intellectual Property" which is protected by Federal Statutes against copyright and trademark infringements. I/we also agree not to compete with Dar-Liens, Inc. in any regard to the preparation of Health Care Provider Liens or Releases for the purpose of filing my/our own Liens and/or Releases by me/us or anyone under my/our employ.

PLEASE COMPLETE THIS PORTION IN THE NAME(S) YOU ARE KNOWN BY THE STATE OF ARIZONA

This form is also available as a PDF document to print and mail to our office or to fax to 602.942.0763. Download this form.

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Agreement	Check This Box To Agree To The Terms Below: we have read this complete Authorization and Contract and agree to all the stipulations contained therein, and agree to pay all legal fees should there be any breach of contract, or if I/we supply any forms and or data for use by anyone else not under contract with Dar-Liens, Inc.