Office of Administrative Hearings Workers222 Compensation Division PO Box 64620 St. Paul, MN 55164-0620 (651)361-7900 Reset P T 0 3 DO NOT USE THIS SPACE Petition for Taxation of Actual and Necessary Disbursements Before: Compensation Judge Court of Appeals See Note on reverse side before drafting. PRINT IN INK or TYPE. Enter dates in MM/DD/YYYY format. PLEASE TAKE NOTICE that the following Bill of Actual and Necessary Disbursements with proof of service on you, will be filed at the Office of Administrative Hearings, PO Box 64620 , St. Paul, Minnesota, 55164-0620 , for taxation and allowance in favor of the applicant. YOU WILL FURTHER TAKE NOTICE that pursuant to the Workers222 Compensation Rules you have ten days from the date of service hereof in which to serve and file any objection to said taxation and allowance with admission or proof of service upon the other parties. Unless you request an opportunity to personally appear to oppose said taxation and allowance, the Court of Appeals or Compensation Judge will consider said petition and any objection thereto based solely on the files, records and proceedings herein and will issue an order thereon. Dated this day of By Attorney for BILL OF ACTUAL AND NECESSARY DISBURSEMENTS WITNESS FEES Name Residence Days and Dates Miles Traveled AMOUNT $ $ $ $ OTHER DISBURSEMENTS State other disbursements, in detail, giving the facts and circumstances showing the necessity and reasonableness of each item, including expert witness fees, attorney fees, or any unusual disbursements, or support such items by separate affidavits.) $ $ $ $ $ $ TOTAL DISBURSEMENTS $ MN PT03 (6/18) (over) EMPLOYEE VS. AND INSURER AND EMPLOYER DATE(S) OF CLAIMED INJURY WID or SSN American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MINNESOTA } } ss. VERIFICATION COUNTY OF } I, , being duly sworn, state that I am an attorney representing the prevailing party, , in the foregoing matter; that the same is a true and correct statement of the actual and necessary disbursements of in said matter, and that all the items thereof have been actually and necessarily paid or incurred therein by or on behalf of said , as more fully appears by additional affidavits hereto attached, marked Exhibits respectively; and that each of the witnesses was a necessary witness for the at the hearing, and each necessarily traveled the number of miles set opposite their name in going from their place of residence to the place of hearing and returning therefrom, and that each necessarily attended the hearing the number of days set opposite their name. Subscribed and sworn to before me this day of Signature Notary Public My Commission expires STATE OF MINNESOTA } } ss. AFFIDAVIT OF SERVICE COUNTY OF } I, , being first duly sworn, state that on , I served a true and correct copy of this document, enclosed in a properly addressed envelope, by depositing the same, with postage prepaid, in the United States mail at , Minnesota, addressed as follows: NAMES AND ADDRESSES Subscribed and sworn to before me this day of Signature Notary Public My Commission expires ATTORNEYS PLEASE NOTE 1. When a case has been heard by a compensation judge and no appeal has been taken from the decision within the time allowed bystatute, taxation of all disbursements is made by the compensation judge.2. When a case has been heard by a compensation judge and thereafter appealed to the Workers222 Compensation Court of Appeals, taxationof all disbursements is made by the Court of Appeals, including those incurred at the hearing before the compensation judge and theCourt of Appeals.3. The opposing party has ten days from the date of service in which to serve and file, with admission or proof of service, a formal objectionto taxation or allowance.4. If required, a time for hearing before the compensation judge or Court of Appeals will be fixed by the Court of Appeals and notice thereofgiven to the parties.5. Pursuant to M.S. 247 176.511, reasonable attorney fees may be allowed if not allowed in the award by the Court of Appeals. This material can be made available in different forms, such as large print, Braille or . To request, call (651) 284-503 or342-5354.ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS222 COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com