2841 Logan Street, Nashville, TN 37211

English (615) 200-8472 · Spanish (615) 601-1LEY (1539) · Fax (615) 301-5811
kimberly@gopallawgroup.com · div@gopallawgroup.com

CONSENT TO RELEASE LIMITED INFORMATION

FOR ADVERTISEMENT/INFORMATIONAL PUPOSES

I, ____________________, am a client of Gopal & Pedigo, PC. I do hereby

voluntarily authorize Gopal & Pedigo, PC to release limited information pertaining
to the services provided and the results of my case with only my first name initial
and full last name or full first name and last name initial(s) for advertisement and
informational purposes only.

Gopal & Pedigo, PC agrees not to release personal information relating to my

address, alien number, date of birth, other information relating to my family, and
social security number. Therefore, I, ____________________, hereby indemnify
Gopal & Pedigo, PC against all claims for damages, compensation and/or costs in
respect to damage or loss to a third party cause by, or arising out of, or bring
incidental to release of my limited information.

Gopal & Pedigo has advised me to seek the advice of legal counsel of my choice
before acting upon any of the information in this document.

_______________________ _________________
SIGNATURE DATE