State of Florida, Office of the Judges of Compensation Claims Claimant Date of Accident: v. OJCC No.: Employer 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 claimant employer/carrier. 3. The attorney fee is by agreement of counsel attorney-client agreement 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. Attorney's Name: First Florida Bar Number: Last ______________________ _________ Attorney's Signature Date OJCC Form AFDS-INT Created 7/1/2005 American LegalNet, Inc. www.FormsWorkflow.com