Attorney Fee Data Sheet
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Attorney Fee Data Sheet Form. This is a Florida form and can be use in Workers Comp.
Tags: Attorney Fee Data Sheet, Florida Workers Comp,
STATE OF FLORIDA
DIVISION OF ADMINISTRATIVE HEARINGS
OFFICE OF THE JUDGES OF COMPENSATION CLAIMS
ATTORNEY FEE DATA SHEET
Date of Accident:
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
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: ______________________
OJCC Form AFDS (Created 1/9/2008)
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