Attorney Fee Data Sheet Additional Attorney Fee In Connection With Settlement
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Attorney Fee Data Sheet Additional Attorney Fee In Connection With Settlement Form. This is a Florida form and can be use in Workers Comp.
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State of Florida, Office of the Judges of Compensation Claims
Claimant
Date of Accident:
v.
OJCC No.:
Employer
Attorney Fee Data Sheet
Additional Attorney Fee in Connection with Settlement
Use this form to report any attorney fee sought to be approved in connection with a washout settlement that is in
addition to fees reportable on form AFDS-WO.
1. Amount of attorney fee for which approval is sought: $
2. The attorney fee is payable by
claimant
employer/carrier.
3. The attorney fee is by
agreement of counsel
attorney-client agreement.
4. The basis for calculation of the attorney fee is:
hourly. The number of hours claimed is
and 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: $ 0.00
5. If the attorney fee is in excess of the statutory percentage formula, state the basis for the
deviation (500 character maximum):
By submitting this document, the attorney attests each entry is accurate and consistent with applicable
instructions, to the best of his or her knowledge, information, and belief.
Attorney's Name:
First
Florida Bar Number:
Last
______________________ _________
Attorney's Signature
Date
OJCC Form AFDS-WOA
Created 7/1/2005
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