Claim Number: APPLICATION FOR LUMP SUM PAYMENT OF ATTORNEY FEES Instructions: Use this form to request an advancement to pay attorney fees, only. The completed application can be filed at any Industrial Commission office. Address on application is new Applicant Information Name Address City, State, Zip Telephone Fax Applicant Representative Information Rep ID# Name Telephone Fax Rep ID# Name Telephone Fax Name Address City, State, Zip Telephone Fax Employer's Representative Information Employer Information The undersigned attorney-at-law, duly authorized by the applicant to represent him/her in the above captioned industrial claim, certifies that: (1) I have rendered the following services for this claim which were necessary to obtain the award for which the advancement to pay the fee is requested: (2) Should the Application for Lump Sum Payment, now under consideration, be granted, the applicant will not be liable for any further fee with respect to continuing compensation, except where a later dispute would arise in this claim, requiring my additional services. (3) Should the Application for Lump Sum Payment include a request for reimbursement of expenses (not to exceed $1,000.00), a copy of the bill has been included with the application. Attorney's Signature (required) Date I, the undersigned applicant, am making application for a lump sum advancement for payment of attorney fees in the amount of $_____________. If the lump sum payment is granted by the Industrial Commission of Ohio, either wholly or in part, I request and authorize the Bureau of Workers' Compensation or self-insuring employer to distribute the lump sum payment directly to the person or persons to whom payment is now due from me, pursuant to any Commission order. This payment will result in a reduction of weekly benefits from my Permanent Total Permanent Partial Death Award. I certify that the above facts on my application are true. Applicant Signature (required) Date IC-32-A An Equal Opportunity Employer and Service Provider Timely, impartial resolution to workers' compensation appeals OIC-3022 Rev. (04.16) American LegalNet, Inc. www.FormsWorkFlow.com