For Office Use Only File Number Office of Attorney Ethics Attorney Fee Arbitration Request Form Date Entered in OAE Database Filing Fee Paid: Yes No A Non-Refundable Filing Fee check in the amount of $50 must be included payable to "Disciplinary Oversight Committee." Please type or clearly print all information: Submit 1 original and 5 copies of all documents submitted, including attachments. A. The Specific Attorney Who Handled My Case Is: (Please list only one attorney here. Please list on a separate sheet the names and addresses of any other attorney whose fee you challenge as part of this fee arbitration proceeding.) Last Name (include: Sr./Jr./III, etc.) First Name Middle Initial Name of Law Firm, If Any, With Which Attorney Was Associated at the Time of Representation Office Address City State Zip County Office Telephone B. Client Information: (Please only list one client name in this section. Please list on a separate sheet the names and address of any other person who should be listed as the "client" in this fee arbitration proceeding.) Last Name (include: Mr./Mrs./Miss/Ms.) First Name Middle Initial Street Address City Home Telephone C. The Type of Case Handled By the Attorney Was: Admiralty/Maritime Adoption/Name Change Bankruptcy/Insolvency/Foreclosure Collection Contract Corporation/Partnership Law Criminal/Quasi-criminal and Municipal Court Domestic Relations (Divorce, Support, Custody) Estate/Probate Federal Remedies / Civil Rights Government Agency Problems (Local Thru Federal) Immigration / Naturalization State Zip County Work or Cell Phone Number International Law Juvenile Delinquency Labor Landlord / Tenant Negligence (Personal Injury Property Damage) Patent / Trademark / Copyright Real Estate Small Claims Court Tax Workers Compensation Other Litigation (specify) Other Non-Litigation (specify) D. What was the amount of the attorney's total bill (not just the fee charged for attorney time or services in dispute)? Total Legal Fee Charged (for attorney time) $ + Total Costs/Disbursements $ Amount paid to Attorney $ Who Paid: Client Other (specify name) page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com = Total Bill $ (attach proof of payment) Revised: 08/2013, CN: 10296 Attorney Fee Arbitration Request Form E. Was there a written fee agreement or fee letter from the attorney explaining how much would be charged? If yes, attach a copy. 1. Had the attorney or law firm ever represented you before accepting this case? Yes No Yes No Yes No 2. Was the fee charged by the attorney contingent on the outcome of the case so that there was no fee due unless the attorney recovered money for you? 3. When did the attorney first agree to handle your case? 4. When did the attorney last do any work on this case? F. Did the attorney advise you in writing that you could request fee arbitration? If yes, attach a copy of that notice or letter, and state the date you received it: Yes No G. Has the attorney brought a lawsuit or other court action against you for the fee? If yes, attach a copy of the complaint or other court filing and list: Docket Number: , County where filed: Date you were served with the complaint or filing: Yes No H. List all amounts paid to the attorney and the dates of payment. Attach copies of all bills received from the attorney and any receipts. I. Briefly explain why you disagree with the attorney's total bill. Use additional sheets, if needed. I further state that, although I have the right to present this matter to a Court in this State, I wish to waive this right and submit my case to the New Jersey Supreme Court's District Fee Arbitration Process. I realize that I have 30 days only from the date this Request Form is docketed within which I may withdraw, in writing, from the arbitration process. Once the request is withdrawn, I cannot again file for fee arbitration. I understand that if the total fee charged is less than $3,000, a single attorney arbitrator may hear the case; otherwise, three arbitrators would decide the case, unless I give my further written consent at the time of the hearing to proceed with two arbitrators, in accord with the procedures set by Court Rule. I agree that the determination of a Fee Committee is final and legally binding upon both the attorney and myself, and that the determination is subject to appeal only in very limited instances of actual fraud, substantial procedural irregularities, failure of an arbitrator to properly be disqualified, or where the arbitrators make an obvious mistake of law. I am further aware that if the attorney has sued me but I have filed a timely Request Form, the Court Rules provide that the lawsuit will be stayed, and "the amount of the fee or refund as so determined [by the Fee Committee] may be entered as a judgment in the action unless the full balance due is paid within 30 days of receipt of the arbitration determination." R. 1:20A-3(e). I also understand that, if no suit is pending, the determination of the Fee Committee may, by summary action, be docketed as a judgment against me, under the same Court Rule. I also understand that fee proceedings are confidential, and I agree to maintain the confidentiality required by R. 1:20A-5. Client Certification I hereby certify that all of the foregoing statements made by me are true, and that all documents attached are true copies of the originals. I am aware that if any part of this Request Form is willfully false, I am subject to punishment. Dated: Signed: Printed Name: Please review the pamphlet "Information About New Jersey Attorney Fee Arbitration System" provided by the Fee Secretary. Please Notify District Secretary of Disability Accommodation Needs, or If You Will Need the Services of an Interpreter. Revised: 08/2013, CN: 10296 page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com