(Office Use Only) Date Received: .................................. Case Number: _________________ UCS 137-4b (10/11) ATTORNEY REQUEST FOR FEE ARBITRATION 1. Your name, address and telephone number: Name: Address: Telephone Number: Email Address: 2. Name, address and office telephone number of the Client whose matter you handled: Name: Address: Telephone Number: Email Address (if known): 3. If you filed a lawsuit on your client’s behalf, in which county and court was the lawsuit filed? Court:__________________________ 4. County: __________________________ a. On what date did you first agree to handle your client’s case? __________________, 20___ b. On what date did you last perform services on your client’s case? __________________, 20___ American LegalNet, Inc. www.FormsWorkFlow.com 5. Briefly describe the type of legal matter involved and what you agreed to do in the course of representing your client (attach a copy of the written retainer agreement, letter of engagement, or other papers describing the fee arrangement, if any): 6. In the space below, indicate the date, amount and purpose of each payment made to you by your client. Attach additional sheets if necessary. Date Amount Purpose (e.g., attorney’s time, out-of-pocket expenses, filing fees, etc.) __________ _________________________________________ __________ $____________ _________________________________________ __________ $____________ _________________________________________ __________ 7. $____________ $____________ _________________________________________ How much of your fee is in dispute (attach a copy of your bill, if available):$______________________________ 8. Have you and your client previously agreed to arbitrate this fee dispute? ________. If yes, please attach a copy of the agreement to arbitrate. 9. Briefly describe why you believe you are entitled to the amount set forth in question 7 (use additional sheets if necessary): American LegalNet, Inc. www.FormsWorkFlow.com 10. Indicate whether you wish to resolve this fee dispute through mediation. (Participation in mediation is voluntary for you and your client, and it does not preclude your client or you from pursuing arbitration under these rules in the event that mediation is unsuccessful; note that the local program with jurisdiction over your fee dispute may not offer mediation). ” Yes, I wish to attempt to resolve this fee dispute first through mediation. ” No, I do not wish to attempt to resolve this fee dispute through mediation. Dated:_____________________________ Signed: ........................................................... IMPORTANT: You must file this Request for Fee Arbitration, along with a check for the filing fee in the amount of $______, to: Local Program Address American LegalNet, Inc. www.FormsWorkFlow.com