Crime Victim Section Office (614) 466-5610 Toll free (800) 582-2877 Fax (614) 752-2732 150 East Gay St., 25th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov American LegalNet, Inc. www.FormsWorkFlow.com Crime Victim Section Office (614) 466-5610 Toll free (800) 582-2877 Fax (614) 752-2732 150 East Gay St., 25th Floor Columbus, Ohio 43215 www.OhioAttorneyGeneral.gov IN RE: CLAIM NO: APPLICANT: ATTORNEY222S STATEMENT REGARDING FEES I, , attorney for the Applicant in the above claim, state under the sanctions of Civil Rule 11 and the penalties of perjury and falsification that: (1) I have not received or contracted for any payment of attorney fees or any fee from my client with respect to this reparations claim; (2) The Itemized Statement of Legal Services filed herewith is an accurate account of the legal services actually rendered; (3) I have read R.C. 2743.65(A) and R.C. 2743.71(B)(3).R.C. 2743.71(B)(3):223An attorney who represents an applicant for an award of reparations cannot chargethe applicant for the services rendered in relation to that representation but is required to apply to the Attorney General for payment for the representation;224 (Emphasis added.) ATTORNEY222S SIGNATURE DATE ATTORNEY222S NAME ATTORNEY222S REGISTRATION NUMBER REQUIRED PAYMENT INFORMATION The warrant in payment of attorney fees will be made payable to the payee, as you direct below, either to your or to your law firm. The payment will be reported to the IRS as income to the name payee. IMPORTANT: The PAYEE and SSN/Tax I.D. number listed below must be the same as listed on IRS Form #-9. PAYEE (Attorney or Attorney222s firm) Payee SSN/Tax I.D. Payee Address American LegalNet, Inc. www.FormsWorkFlow.com 1 American LegalNet, Inc. www.FormsWorkFlow.com 2 American LegalNet, Inc. www.FormsWorkFlow.com