Affidavit for Attorney Fees Under Ohio Revised Code 3121.0311 State of Ohio County of Now comes to law, and deposes and states as follows: , having been duly sworn according 1. Affiant is an attorney licensed to practice law; 2. Affiant is the attorney of record for the obligor, compensation claim number ; , in obligors' workers' 3. Affiant has a written fee agreement with obligor in which affiant is entitled to an attorney fee of percent or (agreement other than a percentage) related to this award, plus expenses related to this award, where applicable. A copy of said agreement is attached hereto; 4. Affiant has provided a copy of the agreement and this signed affidavit to the obligor; 5. Affiant understands that the obligor has been awarded a workers' compensation benefit for (type of compensation) in the amount of $ (total award); 6. Affiant is entitled to attorney fees based on the agreement in statement 3 above and the accrued compensation payable on the date of payment, plus expenses of $ and documented on the attached exhibits; 7. Affiant requests the total payment stated in paragraph six of this affidavit to the attorney at: The attorney's address of record in the claim. The following address: , as itemized Further affiant sayeth naught. Attorney Sworn to and subscribed before me on this day of , 20 . Notary public, State of BWC-1386 C-255 American LegalNet, Inc. www.FormsWorkFlow.com