STATE OF FLORIDA DIVISION OF ADMINISTRATIVE HEARINGS OFFICE OF THE JUDGES OF COMPENSATION CLAIMS ATTORNEY FEE DATA SHEET Claimant Date of Accident: v. OJCC No.: Employer 1. Amount of attorney fee for which approval is sought: ________________. 2. The attorney fee is payable by ____ claimant ____ employer/carrier. 3. The basis for calculation of the attorney fee is: ____ hourly. The number of hours claimed is: ___________. The hourly rate claimed is: ___________. ____ statutory percentage. The benefits secured claimed are itemized in the following table: Description of Benefit Claimed Monetary Value Basis for valuation Total Claimed Monetary Value: ______________________. 4. If this Attorney Fee Data Sheet is submitted in conjunction with a settlement: a. The total amount of claimant’s outstanding child support obligation is: _____________. b. The amount of settlement proceeds to be allocated to child support is: _____________. 5. The amount of costs is (attach itemization of costs for which approval is sought): _____________. 6. If the attorney fee is in excess of the statutory percentage formula, state the basis for the deviation: By submitting this document, the attorney attests each entry is accurate to the best of his or her knowledge, information, and belief. Attorney's Name: ________________________________ Florida Bar Number: ______________________ ______________________ _________ Attorney's Signature Date OJCC Form AFDS (Created 1/9/2008) American LegalNet, Inc. www.FormsWorkflow.com