2. Consideration for Assignment. The consideration for this Assignment and the transaction giving rise to it is [consideration].

3. Description of Assignment. Assignor assigns to Assignee an interest in Assignor's salary, wages, and other compensation for work, labor, and services now due or to become due from Assignor's employer, [name], with offices at [address]. The interest assigned by this Instrument is equal to ---------- dollars ($----------) with interest at the rate of ---------- percent (----------%) per annum from [date].

4. Size of Periodic Payments. Assignor's salary, wages, and other compensation are paid to Assignor weekly. The amounts to be paid to Assignee shall be ---------- percent (----------%) of the gross amount of the weekly compensation received by Assignor, or any larger or smaller sum allowed by law, now or in the future.

5. Authorization to Assignor's Employer. Assignor authorizes his employer to pay the sums assigned to Assignee in accordance with the terms of this Assignment until the total amount assigned has been paid in full. Assignor agrees to hold his employer harmless by reason of these payments.

6. No Other Assignment. Assignor has made no other assignment of and no order of any court has been entered against Assignor's wages, salary, or other compensation in favor of Assignee or any other party.

7. Execution. This Assignment was executed on [date], in [city, state]. Assignor acknowledges the delivery to Assignor of a copy of this Instrument.

[signature]

Assignor

[Acknowledgment]