MN SA04 (6/18) (over) WID or SSN Office of Administrative Hearings PO Box 64620 St. Paul, MN 551 64 - 0620 (651) 361 - 7900 DO NOT USE THIS SPACE DATE(S) OF CLAIMED INJURY EMPLOYEE VS. Statement of Attorney Fees and Costs PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT EMPLOYER(S) AND INSURER(S) AND INSTRUCTIONS TO ATTORNEY: Use this form to r equest attorney fees and costs. Fill in all applicable blanks. Serve all parties. Provide a complete proposed Order Determining Attorney Fees. INSTRUCTIONS TO INSURER OR SELF - INSURED EMPLOYER: If you object to the requested fees or costs you must submit your objection to the Office of A days of the date listed in item 13 (the date this Statement was served). Attach a statement of the amounts currently withheld for attorney fees to the INSTRUCTIONS TO EMPLOYEE : If you object to the requested attorney fees or costs, you mu st submit your objection to the Office of Administrative Hear ings (OAH) at the above address within 10 calendar days of the date listed in item #13 (the date this Statement was d from OAH at t www.dli.mn.gov. If no objection is submitted within 10 days, the attorney fees or costs requested may be awarded. If you do not object to the requested attorney fees you do not need to do anything. You must mail a copy of your objection to the attorney requesting the fees and to the insurer or self - insured employer. You should contact your attorney if you ha ve questions about the requested attorney fees. You may also contact the Department with questions at 651 - 284 - 5032 or toll free at 1 - 800 - 342 - 5354. I am the attorney for the employee, and I certify that the following statements are true: 1. I am an attorney duly licensed to practice law in the state of Minnesota. 2. A copy of the signed retainer agreement is attached to this statement, or was filed with OAH on . 3. The following benefits which were genuinely disputed were recovered for the employee and would not have been recovered but for my involvement: TTD PPD TPD PTD Death Benefits Medical Rehabi litation Retraining Other Amount recovered: $ This blank must be completed for contingency fee claims. 4. Dispute certification under M.S. 247 176.081, subd. 1(c): a. This dispute was certified by the Department of Labor and Industry on (date). b. The Department of Labor and Industry denied certification of this dispute on (date). c. Certification from the Department of Labor and Industry was not required by M.S. 247 176.081, subd. 1(c). 5. The employer/insurer is currently withholding the sum of $ for attorney fees pursuant to M.S. 247 176.081, subd. 1(c). 6. The sum of $ in attorney fees has been previously paid for the same date of injury. 7. I have spent hours in representing the employee in this matter. My hourly fee is $ . 8. I am claiming the following attorney fees: American LegalNet, Inc. www.FormsWorkFlow.com a. From employee benefits: 1) The sum of $ as a contingent fee that does not exceed the limitations of M.S. 247 176.081, subd. 1(a). 2) Fees in excess of the fee limitations of M.S. 247 176.081, subd. 1 in the sum of $ pursuant to Irwin v. Liquor , 599 N.W.2d 132, 59 W.C.D. 319 (Minn. 1999). Attached is the Excess Fee Exhibit with the information required by Minn. Rule 1415.3200, subp. 3, item B. b. From the employer/insurer: 1) The sum of $ as a Roraff - type fee based on the amount recovered, which does not exceed the limitations of M.S. 247 176.081, subd. 1(a)(1). 2) The sum of $ as a Heaton - type fee based on the amount recovered, which does not exceed the limitations of M.S. 247 176.081, subd. 1(a)(1). 3) The sum of $ based on resolution of a non - monetary medical or rehabilitation issue under M.S. 247 176.081, subd. 1(a)(2). 4) The sum of $ under M.S. 247 176.191 payable by 5) The sum of $ , which is in excess of the limitations of under M.S. 247 176.081, subd. 1, pursuant to , 599 N.W.2d 132, 59 W.C.D. 319 (Minn. 1999). Attached is the Excess Fee Exhibit with the information required by Minn. Rule 1415.3200, subp. 3, item B. 9. Application is is not made for payment of attorney fees under M.S. 247 176.08 1, Subd. 7. Amount requested: $ 10. a. I do not know of any other attorney with unsatisfied liens. b. The following attorney has an unsatisfied lien (name and address): 11. The sum of $ has been received from the employee in the form of an expense advancement. 12. a. Request is made for taxation of costs and disbursements for the sum of $ . An itemization of costs incurred and who paid the costs is attached as Exhibit . Receipts have been submitted to the Insurer or self - insured employer. b. Request is not made for taxation of costs and disbursements. 13. A copy of this statement and any exhibits was served on the employee, the employer/insurer and any attorney listed in item 1 0 on (date). Proof of service is attached. 14. I have attached a proposed Order Determining Attorney Fees. PRINT NAME OF ATTORNEY FOR EMPLOYEE ATTORNEY FOR EMPLOYEE SIGNATURE ADDRESS ATTORNEY REGISTRATION NUMBER CITY STATE ZIP CODE TELEPHONE NUMBER This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com