Attorney Fee Data Sheet Additional Attorney Fee In Connection With Settlement

State of Florida, Office of the Judges of Compensation Claims Claimant v. OJCC No.: Employer Date of Accident: Attorney Fee Data Sheet Additional Attorney Fee in Connection with Settlement Use this form to report any attorney fee sought to be approved in connection with a washout settlement that is in addition to fees reportable on form AFDS-WO. 1. Amount of attorney fee for which approval is sought: $ 2. The attorney fee is payable by claimant employer/carrier. 3. The attorney fee is by agreement of counsel attorney-client agreement. 4. The basis for calculation of the attorney fee is: hourly. The number of hours claimed is and the hourly rate claimed is $ statutory percentage. The benefits secured claimed are itemized in the following table: Description of Benefit Claimed Monetary Value Basis for valuation Total Claimed Monetary Value: $ 0.00 5. If the attorney fee is in excess of the statutory percentage formula, state the basis for the deviation (500 character maximum): By submitting this document, the attorney attests each entry is accurate and consistent with applicable instructions, to the best of his or her knowledge, information, and belief. Attorney's Name: First Last Florida Bar Number: ______________________ _________ Attorney's Signature Date OJCC Form AFDS-WOA Created 7/1/2005 American LegalNet, Inc. www.FormsWorkflow.com