Fill and Sign the Attorney Withdrawal Lien State Board of Workers Form

WC-108a ATTORNEY FEE APPROVAL GEORGIA STATE BOARD OF WORKERS' COMPENSATION IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1- 800-533 -0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAININ G OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. §34-9-18 AND §34-9-19). WC -108a REVISION 07/2017 108a ATTORNEY FEE APPROVAL ATTORNEY FEE APPROVAL Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury A. IDENTIFYING INFORMATION EMPLOYEE County of Injury Address E-mail Address City State Zip Code B. REQUEST FOR APPROVAL OF ATTORNEY FEE CONTRACT  Counsel for the employee/claimant requests approval o f the attached fee contract which calls for payment of percent (not to exceed 25%) of all income benefits (which are/have been paid in the amount of $ per week ) commencing / / for a period not to exceed weeks. (Attach supporting documentation) (month) (day) (year) C. REQUEST FOR APPROVAL OF ASSESSED ATTORNEY’S FEE BY CONSENT Counsel for the employee / claimant other: , requests assessment of his / her fee and / or reasonable litigation expenses by consent of parties base d on:  Reasonable value of services in the amount of $ .  Percent (not to exceed 25%) of all income benefits (which are / have been paid in the amount of $ per week. ) commencing / / for a period not to exceed weeks. (month) (day) (year)  Reasonable litigation expenses in the amount of $ . (Attach supporting documentation) D. AGREEMENT OF ALL PARTIES AND COUNSEL FOR RESOLUTION OF FEE LIEN DISPUTE All parties and counsel agree for the Board to appr ove payment of fees as follows: Specify which attor ney should receive which fee, and whether the fee s hould be assessed as a lump sum amount or as percentage b ased on income benefits, the date commenced, and the percentage to be applied (not to exceed 25%). E. CERTIFICATE OF SERVICE  I certify the fee which I am requesting represents the fair and reasonable value of my services, and complies with O.C.G.A. § 34-9-108 and Board Rule 108. I have today sent a copy of this request to all counsel and unrepresented parties in this action. CONSENTED TO BY: Signature Date Signature Date Print Name Print Name E-mail GA Bar Number E-mail GA Bar Number Address Address City State Zip Code City State Zip Code