WORKER'S SETTLEMENT STATEMENT Michigan Department of Licensing and Regulatory Affairs Workers' Compensation Agency PO Box 30016, Lansing, MI 48909 Plaintiff v. 1a. Current Settlement Payment 1b. 70% Benefits Paid (if any) 1c. Total Redemption Settlement Amount ATTORNEY EXPENSES UNDER R408.44(5) 2a. 2b. 2c. 2d. 2e. Total Expenses ATTORNEY FEE CALCULATION UNDER R408.44(3)(4)(7) 3a. 3b. 3c. 3d. 3e. 4. %X Total Attorney Fee Redemption Fee Base for Fee Calculation (Total Redemption Minus Total Expenses) % of first $25,000 % above $25,000 = = = $ $ $ $ $ $ $ $ Defendant $ $ $ $ $ $ 100.00 DIRECT PAYMENTS 5a. 5b. 5c. 5d. 6. 7. 8. Total Direct Payments 70% Benefits Paid $ $ $ $ $ $ $ Total Expenses, Attorney Fees, Redemption Fee, Direct Payments and 70% Benefits Net Amount to Plaintiff (1c minus 7) Date I certify that I have read and approved of this statement. Plaintiff Attorney for Plaintiff LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities. WC-544 (Rev. 5/12) Authority: Completion: Penalty: R408.44(3) Voluntary None American LegalNet, Inc. www.FormsWorkFlow.com