STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS ) ) Claimant, ) ) vs. ) ) , ) Employer's name, ) Employer/Carrier. ) _____________________________) , Employee's name, OJCC Case No.__________________ Judge Assigned:________________ Date of Accident:____/____/____ MOTION FOR APPROVAL OF ATTORNEY'S FEE AND ALLOCATION OF CHILD SUPPORT ARREARAGE FOR SETTLEMENTS UNDER SECTIONS 440.20(11)(c), (d), and (e), FLORIDA STATUTES 1. The parties have reached a settlement agreement arising out of the above-styled industrial accident. 2. Pursuant to the contract of representation, the Claimant has agreed to pay his attorney a fee for services rendered in obtaining this settlement. 3. The total amount of the settlement is $__________. The Claimant agrees to pay and counsel agrees to accept the sum of $__________ for attorney's fees which is is not within the statutory percentages set forth in Section 440.34, Florida Statutes. The Claimant agrees to pay and counsel agrees to accept the sum of $__________ for costs. The net settlement of the Claimant after fees and costs will be $__________. 4. The Claimant understands that he may request a hearing to determine a reasonable fee to be paid under the circumstances of this case. The Claimant waives his/her right to a hearing on this issue. 5. The child support arrearage is _________ according to the report on the OJCC docket dated ________." [If no arrearage, enter "0"]. The claimant agrees that the sum of $_________ shall be withheld from the settlement proceeds and paid directly to the proper authorities. [Statement regarding whether claimant's attorney or carrier is paying the child support arrearage from settlement.] American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, the Claimant and the undersigned counsel, request entry of an order approving the attorney's fee to be paid from the settlement proceeds and the child support arrearage allocation under this settlement. Dated this ____ day of ___________________, 20___. ______________________________ ______________________________ Employee Counsel of Record CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the above motion has been mailed on this ______ day of ___________________, 20____, to counsel of record and to the parties at the address below, if unrepresented. _______________________________ (signature) COPIES FURNISHED: employee employee's address of record carrier carrier's address of record 2 American LegalNet, Inc. www.FormsWorkFlow.com