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By submitting this form I am authorizing Daffner & Associates to gather more information and do preliminary research regarding my issues. This form DOES NOT create an attorney-client relationship and I WILL NOT be billed for any work done pursuant to this form unless I specifically contract with Daffner & Associates to provide representation in my case. The submission of this form DOES NOT in any way obligate me to retain (hire) the firm with respect to my case, and the firm will not disclose any of my personal information to any third parties.

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