For office use: Closing Statement – NYCRR §§603.7, 691.20 CLOSING STATEMENT TO: OFFICE OF COURT ADMINISTRATION—Statements PO Box 2016 New York, NY 10008 1. Code number appearing on Attorney's receipt for filing of retainer statement: ______________________________________________ 2. Name and present address of client: __________________________ _______________________________________________________ _______________________________________________________ 3. Plaintiff(s) 5. (a) If an action was commenced, state the date: _____________, 20___, _______________ Court, ___________________ County. (b) Was the action disposed of in open court? ___ If not, and a request for judicial intervention was filed, state the date the stipulation or statement of discontinuance was filed with the clerk of the part to which the action was assigned: _____________, 20___. If not, and an index number was assigned but no request for judicial intervention was filed, state the date the stipulation or statement of discontinuance was filed with the County Clerk: _____________, 20___. 6. Check items applicable: Settled; Claim abandoned by client; Judgment. Date of payment by carrier or defendant ____________, 20___. Date of payment to client: ____________, 20___. 7. Gross amount of recovery (if judgment entered, include any interest, costs and disbursements allowed): $_____________ (of which $_____________ was taxable costs and disbursements). 8. Name and address of insurance carrier or person paying judgment or claim and carrier's file number, if any: ______________ ___________________________________________________________________________________________________ 9. Net amounts: to client $______________; compensation to undersigned $______________; names, addresses and amounts paid to attorneys participating in the contingent compensation: ________________________________________________ ___________________________________________________________________________________________________ 4. Defendant(s) 10. Compensation fixed by: retainer agreement; under schedule; or by court. 11. If compensation fixed by court: Name of Judge _____________________________, Court ________________, Index No. _____________, date of order ____________, 20___. 12. Itemized statement of payments made for hospital, medical care or treatment, liens, assignments, claims and expenses on behalf of the client which have been charged against the client's share of the recovery, together with the name, address, amount and reason for each payment: ___________________________________________________________________________ ___________________________________________________________________________________________________ 13. Itemized statement of the amounts of expenses and disbursements paid or agreed to be paid to others for expert testimony, investigative or other services properly chargeable to the recovery of damages together with the name, address and reason for each payment: _____________________________________________________________________________________________________ ___________________________________________________________________________________________________ 14. Date on which a copy of this closing statement has been forwarded to the client: ____________, 20___. Dated: ______________________________, NY, this ______ day of _________, 20___. Signature of Attorney Signature of Attorney Print attorney name Print attorney name Office and P.O. Address _____ Dist. _____________________________ County Office and P.O. Address _____ Dist. ____________________________ County [If space provided is insufficient, additional 8½” x 11” sheet(s) signed by attorney may be attached.] NOTE: CPLR 2104 and 3217 REQUIRE THAT THE ATTORNEY FOR THE DEFENDANT FILE A STIPULATION OR STATEMENT OF DISCONTUANCE WITH THE COURT UPON DISCONTINUANCE OF AN ACTION. American LegalNet, Inc. www.FormsWorkFlow.com