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DEPICTION RELEASE

GRANT WITH REVERSION FORMAT CONSENT AND RELEASE

To: XXXXXXXXXXXXX Incorporated, a XXXXXXXXXXXXX Corporation.

I understand that you desire to use all or parts of the events of my life in order to have
one or more teleplays or screenplays written, and to produce, distribute, exhibit and
exploit one or more television programs and/or motion pictures of any length in any
media now known or hereafter devised and sound recordings in any media now known or
hereafter devised. I have agreed to grant you certain rights in that connection. This
Consent and Release confirms our agreement as follows:

1. CONSIDERATION; GRANT OF RIGHTS: In consideration of your efforts to produce


my story, payment to me of $$$$$$$$$$$$$ upon the beginning of principal photography
of a full-length Theatrical Motion Picture, and/or $$$$$$$$$$$$$ upon the beginning of
production of a television movie, and/or $$$$$$$$$$$$$ upon the beginning of
production of a pilot program and a royalty of $$$$$$$$$$$$$ for each episode
thereafter, and for other valuable consideration, with full knowledge I hereby grant you,
perpetually and irrevocably, the unconditional and exclusive right throughout the world
to use, simulate and portray my name, likeness, voice, personality, personal identification
and personal experiences, incidents, situations and events which heretofore occurred or
hereafter occur (in whole or in part) based upon or taken from my life or otherwise in and
in connection with motion pictures, sound recordings, publications and any other media
of any nature at all, whether now known or hereafter devised. Without limiting the
generality of the foregoing, it is understood and agreed that said exclusive right includes
theatrical, television, dramatic stage, radio, sound recording, music, publishing,
commercial tie-up, merchandising, advertising and publicity rights in all media of every
nature whatsoever, whether now known or hereafter devised. I reserve no rights with
respect to such uses. (All said rights are after this called the "Granted Rights". It is further
understood and agreed that the Granted Rights may be used in any manner and by any
means, whether now known or unknown, and either factually or with such
fictionalization, portrayal, impersonation, simulation and/or imitation or other
modification as you, your successors and assigns, determine in your sole discretion. I
further acknowledge that I am to receive no further payment with respect to any matter
referred to herein. Any and all of the Granted Rights shall be freely assignable by you.

2. PAYMENT OF CONSIDERATION; REVERSION OF RIGHTS: I understand that


you shall make the payments mentioned in paragraph 1 only if you begin production of a
feature film or television movie or television pilot. In the event that you do not begin
such a production within XXXXXXXXXXX years of the date this agreement was
executed, all rights granted by me under this agreement shall revert to me. I understand
that if you do begin production within XXXXXXXXXXX years of the date this
agreement was executed, all rights granted by me under this agreement shall be perpetual.
3. RELEASE: I agree hereby to release and discharge you, your employees, agents,
licensees, successors and assigns from any and all claims, demands or causes of actions
that I may now have or may hereafter have for libel, defamation, invasion of privacy or
right of publicity, infringement of copyright or violation of any other right arising out of
or relating to any utilization of the Granted Rights or based upon any failure or omission
to make use thereof.

4. NAME - PSEUDONYM: You have informed me and I agree that in exercising the
Granted Rights, you, if you so elect, may refrain from using my real name and may use a
pseudonym which will be dissimilar to my real name, however, such agreement does not
preclude you from the use of my real name should you in your sole discretion elect and
that in connection with it I shall have no claim arising out of the so-called right of privacy
and/or right of publicity.

5. FURTHER DOCUMENTS: I agree to execute such further documents and instruments


as you may reasonably request to effectuate the terms and intentions of this Consent and
Release, and in the event I fail or am unable to execute any such documents or
instruments, I hereby appoint you as my irrevocable attorney-in- fact to execute any such
documents and instruments, if said documents and instruments shall not be inconsistent
with the terms and conditions of this Consent and Release. Your rights under this Clause
constitute a power coupled with an interest and are irrevocable.

6. REMEDIES: No breach of this Consent and Release shall entitle me to terminate or


rescind the rights granted to you herein, and I hereby waive the right, in the event of any
such breach, to equitable relief or to enjoin, restrain or interfere with the production,
distribution, exploitation, exhibition or use of any of the Granted Rights granted, it being
my understanding that my sole remedy shall be the right to recover damages with respect
to any such breach.

7. PUBLIC DOMAIN MATERIAL: Nothing in this Consent and Release shall ever be
construed to restrict, diminish or impair the rights of either you or me to use freely, in any
work or media, any story, idea, pilot, theme, sequence, scene, episode, incident, name,
characterization or dialogue which may be in the public domain from whatever source
derived.

8. ENTIRE UNDERSTANDING: This Consent and Release expresses the entire


understanding between you and me, and I agree that no oral understandings have been
made with regard thereto. This Consent and Release may be amended only by written
instrument signed by you and me. I acknowledge that in granting the Granted Rights I
have not been induced to do so by any representations or assurances, whether written or
oral, by you or your representatives concerning the manner in which the Granted Rights
may be exercised and I agree that you are under no obligation to exercise any of the
Granted Rights and agree I have not received any promises or inducements other than as
herein set forth. The provisions hereof shall be binding upon me and my heirs, executors,
administrators and successors. I acknowledge that you have explained to me that this
Consent and Release has been prepared by your attorney and that you have recommended
to me that I consult with my attorney concerning this Consent and Release. This Consent
and Release shall be construed according to the laws of the State of California applicable
to agreements which are fully signed and performed within the State of California and I
hereby waive any rights I may have, known or unknown, pursuant to Section 1542 of the
California Civil code which provides:

"A general release does not extend to claims which the creditor does not
know or suspect to exist in his favor at the time of executing the release,
which if known by him must have materially affected his settlement with
the debtor."

In witness hereof and in full understanding of the foregoing, I have signed this Consent
and Release on this XXXXXXXXXXX.

______________________
(Signature)

______________________
(Name, please print)

______________________
(Address)

AGREED:

______________________
by:____________________
XXXXXXXXXXXXX (Production Company)