Request For Approval Of Attorneys Fees {DC-AF 1}

STATE OF HAWAII DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DISABILITY COMPENSATION DIVISION AND LABOR AND INDUSTRIAL RELATIONS APPEALS BOARD REQUEST FOR APPROVAL OF ATTORNEY222S FEE Notice is hereby given to the Director of Labor and Industrial Relations and/or the Labor and Industrial Relations Appeals Board that the undersigned performed services as counsel in the following case for: Claimant: vs. Employer:002 DCD Case No.: 002AB Case No.: Attached is a statement itemizing the services provided for claimant(s), the time spent on each service (rounded to the nearest one-tenth of an hour), and the costs advanced. Also attached are receipts documenting the costs advanced. The itemized statement is summarized below: : DCD Attorney Hourly Rate: $ Per Hour Attorney Total HoursHours Paralegal Hourly Rate: $ Per Hour Paralegal Total Hours: Hours Fee Requested: $Tax: $ Costs Requested: $DCD WC-17 Box # Requested: Appeals Board Attorney Hourly Rate: $ Per Hour Attorney Total Hours: Hours Paralegal Hourly Rate: $ Per Hour Paralegal Total Hours: Hours Fee Requested: $ Tax: $ Costs Requested: $ Fees and Costs totaling $ are sought for the foregoing services, and approval thereof is hereby requested in accordance with Chapter 386, Hawaii Revised Statutes. This request was served upon on as required pursuant to 247 12-47-55 of the Appeals Board222s Rules and/or 247 12-10-69 of the Disability Compensation Division222s Rule. Any Party may file a written objection to this request for approval no later than ten calendar days after service. Required Attorney Information: I have approximately years222 experience in workers222 compensation cases. I have participated in approximately cases before the Disability Compensation Division over the last 3 years. I have participated in approximatelycases before the Labor and Industrial Relations Appeals Board over the last 3 years. I certify that the above information is submitted in good faith and is true and accurate to the best of my knowledge and belief. Signature: Name (print): Date: Mailing Address: City, State, ZIP: DC/AB 1 (REV. 12/2012) American LegalNet, Inc. www.FormsWorkFlow.com