Attorney Fee Data Sheet Attorney Fee Not In Connection With Settlement
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Attorney Fee Data Sheet Attorney Fee Not In Connection With Settlement Form. This is a Florida form and can be use in Workers Comp.
Tags: Attorney Fee Data Sheet Attorney Fee Not In Connection With Settlement, Florida Workers Comp,
State of Florida, Office of the Judges of Compensation Claims
Date of Accident:
Attorney Fee Data Sheet
Attorney Fee Not in Connection with Settlement
Use this form to report any attorney fee sought to be approved in any case in which a washout settlement agreement
has not been reached and is not expected.
1. Amount of attorney fee for which approval is sought: $
2. The attorney fee is payable by
3. The attorney fee is by
agreement of counsel
order of Judge.
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.
Florida Bar Number:
OJCC Form AFDS-INT
American LegalNet, Inc.