Power Of Attorney Form
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1Power of Attorney Form
The Deepwater Horizon Economic and Property Damage Settlement Agreement requires that the claimant sign the
Registration Form and Claim Form. An attorney may sign online or on a hard copy for the claimant if the attorney or the
attorney’s firm has a power of attorney, retainer agreement or other document signed by the claimant authorizing the
attorney or the firm to pursue on behalf of the claimant any claims arising out of the Deepwater Horizon Incident. This
Form is not required of all attorneys, but an attorney or firm that does not already have such a document may have the
claimant sign this Power of Attorney Form to satisfy that requirement. An attorney may not sign this Form. While the
Claimant must sign this Form, you may submit this in a PDF image and do not have to submit the original hard copy. A
form authorizing an attorney or firm to pursue claims with the GCCF is not sufficient.
A. Claimant Information
Last Name or Full Name of Business
First Name
Middle Initial
Name:
Deepwater Horizon Settlement Program Claimant Number:
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SSN or ITIN
Social Security Number:
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Individual Taxpayer Identification Number:
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EIN
Employer Identification Number:
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Street
Current Address:
City
State
Zip Code
B. Attorney Information
Law Firm Name:
Last Name
First Name
Middle Initial
Attorney Name:
Street
Law Firm Address:
City
State
Zip Code
Attorney Phone Number:
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Attorney Email Address:
C. Signature
I certify to the Deepwater Horizon Economic and Property Damage Settlement Program that the attorney(s) at the law
firm identified in Section B are authorized to pursue on my behalf any claims arising out of the Deepwater Horizon Incident
and to execute on my behalf any Registration Form and/or Claim Form that must be submitted on my behalf under penalty
of perjury in support of a claim and I understand that the Claims Administrator will treat such signature as my signature. I
authorize the Claims Administrator to communicate directly with such attorney(s) and other representatives of the law firm
and understand that the Claims Administrator will not communicate with me in any manner without express written
permission from the attorney(s) at the law firm.
_____/_____/______
Signature:
Date:
(Month/Day/Year)
Last Name
First Name
Middle Initial
Name:
Title (If a Business):
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