[Date]
[Address]
FOR VALUE RECEIVED, the undersigned hereby sells
and transfers to [Assignee] and its successors, assigns and
personal representatives, any and all claims, demands, and
cause or causes of action of any kind whatsoever which the
undersigned has or may have against [name], arising from the
following type claim: [Description]
And the undersigned may in its own name and for its own
benefit prosecute, collect, settle, compromise and grant releases
on said claim as it in its sole discretion deems advisable.
Signed under seal this [date] day of [month, year].
________________________________________
(clearly print name after signature)
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