STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS , ) Employees name ) Claimant, ) ) vs. ) OJCC Case No.__________________ ) Judge Assigned:________________ , ) Date of Accident:____/____/____ Employers name ) Employer/Carrier. ) _____________________________) AFFIDAVIT IN SUPPORT OF ATTORNEYS FEES IN EXCESS OF STATUTORY GUIDELINE STATE OF FLORIDA COUNTY OF _____________________ Being duly sworn, , attorney for the Claimant in this cause, in support of approval of an attorneys fee which exceeds the otherwise applicable statutory guideline fee, affirms and states as follows: 1. The affiant has been instrumental in obtaining the following benefits for the Claimant: [List applicable monetary and/or medical benefits]________________________________________ _______________________________________________________________; 2. The guideline fee as set forth in Section 440.34, Florida Statutes [state applicable year], ________ is $___________; 3. The affiant has expended _____________ hours in securing the above on behalf of the Claimant; 4. The statutory guideline fee should be enhanced because of the following statutory factors: [List applicable statutory factors, including hourly rate claimed] _________________________ ________________________________________________________________; 5. That a reasonable attorney fee for Claimants counsel in this matter is in the amount of $___________; 6. The counsel for the Claimant hereby certifies that no fee for obtaining the above benefits has previously been paid; and American LegalNet, Inc. www.USCourtForms.com>>>> 2 7. The affiant has fully discussed this matter with the Claimant/Client, who has agreed to payment of the fee as set forth in paragraph No. 5. Dated this _____ day of _____________________, 200___, in ______________ County, Florida. _____________________________ Attorney for the Claimant [address of record] SWORN TO AND SUBSCRIBED before me this _____ day of ____________, 200___, in ______________ County, Florida, by [Claimants Attorney] ________________________________________, and who did take an oath. _____________________________ NOTARY PUBLIC STATE OF FLORIDA My Commission Expires on: 2 American LegalNet, Inc. www.USCourtForms.com