Legal claims for damages associated with Medicare Secondary Payer : License, Sale, Declaration and Assignment
SALE, LICENSE, DECLARATION AND ASSIGNMENT
WHEREAS, the undersigned ORIGINAL CLAIM HOLDERS(s), hereinafter referred to as the “ORIGINAL CLAIM HOLDER”, who has an “ORIGINAL CLAIM”, whose residence is listed below:
WHEREAS, the under signed ORIGINAL CLAIM HOLDERS(s), hereinafter referred to as the “ORIGINAL CLAIM HOLDER”, who has an “ORIGINAL CLAIM”, who residence is listed below:
has sold an ORIGINAL CLAIM(s) and which was injured or damaged in home, business and/or person during:
AS AN ORIGINAL CLAIM HOLDER, I hereby declare that:
The ORIGINAL CLAIM(S) identified and submitted on the CirclesX platform were done to my home, business, and/or person;
I believe I am the ORIGINAL CLAIM HOLDER who sustained an ORIGINAL CLAIM(S) as a Medicare recipient or assignee.
I hereby acknowledge that any willful false statement made in this declaration is punishable under 18 USC 1001 by fine or imprisonment of not more than five (5) years, or both;
I have created an account on CirclesX platform and have agreed to the software license agreement.
I have reviewed and understand the contents of the application, including the claims; and
I acknowledge the duty to disclose information which is material to the ORIGINAL CLAIM(S).
AND WHEREAS, THE VAULTSX SERIES I LP, hereinafter referred to as “COMPANY”, having a place of business at 12434 Kingsride #418, Houston, Texas 77024, is desirous of acquiring or confirming its acquisition of the entire right, title and interest in and to said ORIGINAL CLAIM, past, current and future, in the United States and of all foreign countries, that may be obtained thereof.
NOW, THEREFORE, TO ALL WHOM IT MAY CONCERN, BE IT KNOWN, that the undersigned ORIGINAL CLAIM HOLDER, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, has unconditionally sold, assigned, transferred and conveyed, and/or by this assignment does hereby sell, assign, transfer and convey, unto said COMPANY, its successors and assigns, the entire right, title and interest throughout the world, in in and to the above-described ORIGINAL CLAIM, or derivatives of ORIGINAL CLAIM, in any form or embodiment thereof, and in and to said ORIGINAL CLAIM, and in and to any ORIGINAL CLAIM filed in any foreign country based thereon, including the right to file a claim under the provisions of any convention or treaty; and in and to any confirmation, which may be filed on said ORIGINAL CLAIM(S), or derivatives of ORIGINAL CLAIM(S) in the United States or in any foreign country; and in and to any and all ORIGINAL CLAIM(S) or confirmations thereof which may be claimed or granted in the United States or in any foreign country upon said ORIGINAL CLAIM or ORIGINAL CLAIM derivatives.
The same to be held and enjoyed by said COMPANY for its own use and enjoyment, and for its legal representatives and assigns, to the full end of the term or terms for which any and all such United States and foreign settlement or judgement (“Claim Recovery”) may be issued on said ORIGINAL CLAIM, or ORIGINAL CLAIM derivatives, as fully and entirely as the same would have been held by ORIGINAL CLAIM HOLDER had this assignment and transfer not been made; and, including, but not limited to, the right to sue for past, present and injury or damages of said ORIGINAL CLAIM(S) and to benefit from injunctions against past, present and future tortfeasors, and to recover damages, profits and attorneys fees relative to such past, present and future tortfeasors of ORIGINAL CLAIM(S).
AND said ORIGINAL CLAIM HOLDER does hereby authorize and request the issuing authority of settlements or judgements to issue any and all of said United States and foreign claim recovery on said ORIGINAL CLAIM(S) or ORIGINAL CLAIM(S) derivative to said COMPANY, its successors and assigns, as the assignee of the entire right, title and interest in and to the same, for the sole use and benefit of said COMPANY, its successors and assigns.
AND said ORIGINAL CLAIM HOLDER does hereby covenant and warrant that said ORIGINAL CLAIM HOLDER has full right to convey the entire right, title and interest herein assigned free and clear of all claims, subrogate claims, licenses, encumbrances and liens whatsoever, and that said ORIGINAL CLAIM HOLDER has not executed or will execute any instruments in conflict herewith.
AND said ORIGINAL CLAIM HOLDER, in connection with the license of software, sale, assignment, transfer, the ORIGINAL CLAIM HOLDER, has an interest in the improved claim and may be given limited access to software, claim and data by the COMPANY which is non-public, confidential and proprietary in nature (the “CONFIDENTIAL INFORMATION”). In consideration of the COMPANY furnishing the ORIGINAL CLAIM HOLDER, with the CONFIDENTIAL INFORMATION, and in condition to such disclosure, the ORIGINAL CLAIM HOLDER agrees to keep the CONFIDENTIAL INFORMATION confidential and will not disclose the CONFIDENTIAL INFORMATION to anyone except the ORIGINAL CLAIM HOLDER. The ORIGINAL CLAIM HOLDER, recognizes the competitive value of CONFIDENTIAL INFORMATION if the CONFIDENTIAL INFORMATION is disclosed to a third party.
AND said ORIGINAL CLAIM HOLDER, for the conditions aforesaid, does hereby covenant and agree to and with said COMPANY, its successors and assigns, that said ORIGINAL CLAIM HOLDER, his or her executors, administrators, or other personal representatives, shall and will do all lawful acts and things, make all rightful oaths, and make, execute and deliver any and all other instruments in writing, and any and all further applications, papers, powers, affidavits, assignments, disclaimers, photographs, models, samples or other physical exhibits and other documents, which in the opinion of said COMPANY, its successors and assigns, may be required or necessary in this or in any foreign country more effectually to secure to and vest in said COMPANY, its successors and assigns, the entire right, title and interest in and to said ORIGINAL CLAIM, ORIGINAL CLAIM derivatives, public adjustment opinions and claims, rights, titles, benefits, privileges, and advantages hereby sold, assigned, confirmed, transferred and conveyed.
ORIGINAL CLAIM HOLDER(S)
/Erik M Simpson/
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