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__________________ $__________________ $__________________ $__________________ __________________________________ Signature of Client ________________________ Date _____ _______________________________ _______________________________ _______________________________ Total Payments NET PAYMENT TO CLIENT $__________________ $__________________ $__________________ $$__________________ $__________________ $__________________ Total Attorney fees & costs $__________________ MEDICAL LIENS & OTHER PAYMENTS: _______________________________ __________________________edical records: Police Report : Legal Fees : Copies : Telephone : Faxes : Misc. : $_____________ $_____________ $_____________ $_____________ :$_____________ $_____________ $_____________ Total Costs ty. The purchase and use of this form is subject to the "Terms and Conditions" found at www.FindLegalForms.com DISBURSAL SHEET TOTAL AMOUNT OF SETTLEMENT ATTORNEY'S FEES ________% ATTORNEY'S COSTS: Mce. This form should only be a starting point for you and should not be used without first consulting with an attorney. An attorney should be consulted before negotiating any document with another par for multi-state use. State law and your state's bar organization may require additional language for this form to be considered valid. This form is not intended and is not a substitute for legal adviInformation Settlement Disbursal Sheet Bracketed instructions may be included on this form to assist you in completing it and should be removed before printing. Please note that this form was designed