Retainer Statement (Sliding Scale Terms) – NYCRR §§603.7, 691.20 For office use: RETAINER STATEMENT TO: OFFICE OF COURT ADMINISTRATION—Statements PO Box 2016 New York, NY 10008 1. Date of agreement as to retainer: _____________________ 2. Terms of compensation1: (i) 50 percent on the first $1,000 of the sum recovered (ii) 40 percent on the next $2,000 of the sum recovered (iii) 35 percent on the next $22,000 of the sum recovered, (iv) 25 percent on any amount over $25,000 of the sum recovered [paragraph (e)(2) of NYCRR §603.7 or §691.20]. 3. Name and home address of client: _____________________________________________________________ _________________________________________________________________________________________ 4. If engaged by an attorney, name and office address of retaining attorney2: _____________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 5. If claim for personal injuries, wrongful death or property damage, date and place of occurrence: ____________ _________________________________________________________________________________________ _________________________________________________________________________________________ 6. If a condemnation or change of grade proceeding: (a) Title and description: ______________________________________________________________________ ___________________________________________________________________________________________ (b) Date proceeding was commenced: ____________________________________________________________ (c) Number or other designation of the parcels affected: ______________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 7. Name, address, occupation and relationship of person referring the client: ______________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Dated: ___________________, NY, this ______ day of ________, 20__. Signature of Attorney Print attorney name Office and P.O. Address _____ Dist. ___________________________ County 1 In the case “of extraordinary circumstances, . . . application for greater compensation may be made” [see paragraph (e)(4) of NYCRR § 603.7 (First Department) or § 691.20 (Second Department)]. 2 Also include particulars as to the fee arrangement, the type of services to be rendered in the matter, the code number assigned to the statement of the retainer filed by the retaining attorney and the date when said statement of retainer was filed. 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