FOR VALUE RECEIVED， the undersigned hereby sells and transfers to _， [Assignee] and its successors， assigns and personal representatives， any and all claims， demands， and cause or causes of action of any kind whatsoever which the undersigned has or may have against _， arising from the following type claim：

　　_

　　And the undersigned may in its own name and for its own benefit prosecute， collect， settle， compromise and grant releases on said claim as it in its sole discretion deems advisable.

　　Signed under seal this _ day of _， 19_.

　　________________________________