This Settlement Disbursal Sheet sets forth a client's net payment after settlement of a lawsuit. This disbursement sheet sets out the total amount of the settlement, percentage paid as attorney's fees, costs (such as fees for copies, phone calls and reports), medical liens and net settlement amount due to the client. This Settlement Disbursement Sheet is simple to use and can easily be tailored to fit the unique needs of your cases.

This Settlement Disbursal Sheet includes the following:

• Total: Sets out the total amount which was paid to settle the case;
• Attorney Fees: Percentage amount of the settlement which was agreed to as an attorney fee;
• Costs: Detailed description of all costs paid on the client's behalf which may include medical records, police reports and in-house copies;
• Liens: Medical liens and other payments which were promised to providers or experts who rendered services on client's behalf;
• Net Payment: Net settlement payment to client after all other fees have been deducted;
• Signature: The client must sign and date this disbursal sheet which will act as acknowledgment of payment.

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This attorney-prepared packet contains:

1. Information
2. Settlement Disbursal Sheet

State Law Compliance: This form complies with the laws of all states