UCS 137-12 (10/03) _____________________________ In the Matter of Fee Dispute Arbitration between (Office Use Only) , Client and ARBITRATION AWARD , Attorney ___________________________________ 1. The AMOUNT IN DISPUTE is: $ _______________ 2. The TOTAL of the AMOUNT IN DISPUTE to which the attorney is entitled is (including all costs and disbursements and amounts previously paid by the client): $ _______________ The AMOUNT of this total PREVIOUSLY PAID by the client is: $ _______________ 3. 4. (a) The BALANCE DUE by the client to the attorney is: $ _________ -OR(b) The AMOUNT TO BE REFUNDED by the attorney is: $ _________ Statement of Reasons: AFFIRMATION The undersigned arbitrator(s), having been duly appointed pursuant to the Rules of Local Program Name , and pursuant to any applicable Rule of the Chief Administrator, Title 22, of the Official Compilations of Codes, Rules and Regulations, or the Agreement of the parties to the dispute resolved by this award, and having duly taken the oath according to the law and having duly heard the proofs and allegations of the parties hereto, hereby affirm(s), pursuant to CPLR 7507, under the penalties of perjury, that the above award is a true, correct and complete statement of the award rendered in the above-captioned arbitration, duly executed by the undersigned. (Signatures of Arbitrator(s); print name below signatures) Dated:_______________________ [Mail copy to each party] American LegalNet, Inc. www.FormsWorkflow.com