State of Florida, Office of the Judges of Compensation Claims Claimant Date of Accident: v. OJCC No.: Em ployer Attorney Fee Data Sheet- Washout Settlement Use this form to report any attorney fee sought in conectionn with a settlement. If an Additional Attorney Fee Characterized as being paid by the carrier is soughcont in nection with the settlement, that fee must be reported separately on form AFDS-WOA. Fees sought in cases which are not being finally settled must be reported instead on form AFDS-INT. 1. Total amount paid to obtain settlement (including all fees and costs, but exclusive of any fees being reported on form AFDS-WOA in this case): $ 2. Value of benefits previously paid tor o on behalf of claimant, due to attorneys efforts, for which no attorney fee has been paid to date: $ 3. Total amount of claimants outstandin child g support obligation, if any: $ 4. Amount of settlement proposed to be allocated to child support: $ 5. Amount of Settlement Proceeds allocated to attorneys fees (exclusive of any fees reported on form AFDS-WOA in this case): $ 6. Sum of all other attorneys fees previously paid in this case: $ 7. Amount of costs to be paid from settlement proceeds: $ 8. Relationship of Proposed Fee to Statutory Percentage Formula (select one) 8(a). Attorney fee is pursuant to statutory percentage formula. 8(b). Statutory formula results in unreasonably low hourly rate (Accidents prior to 10-1-03, Davis v. Keeto, 463 So. 2d 368 (1st DCA 1985)). Enter hours here: 8(c). Medical Only Claim (Accidents after 9-30-03)(S. 440.34(7) F.S.). Enter hours here: 8(d). Other basis, or statutory formula does not apply. 8(e). If "other basis" is checked, enter explanation (500 char. max.): 9. Check here if an attorney fee requiring submission of form AFDS-WOA is being sought in this case. 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. Attorneys Name: First Last ______________________ _________ Florida Bar Numb:er Attorneys Signature Date OJCC Form AFDS-WO Created 7/1/2005 American LegalNet, Inc. www.USCourtForms.com