Fill and Sign the Fee Arbitration Program State Bar of Wisconsin Form

State Bar of Wisconsin 5302 Eastpark Blvd. u P.O. Box 7158 u Madison, WI 53707-7158 (800)728-7788 u (608)257-3838 u Fax (608)257-5502 u Internet: www.wisbar.org u Email: service@wisbar.org REQUEST AND RESPONSE FORM FOR ARBITRATION OF FEE DISPUTE With the State Bar of Wisconsin Fee Arbitration Program Return Form To: Committee on Resolution of Fee Disputes State Bar of Wisconsin, P.O. Box 7158, Madison, WI 53707-7158  An arbitration hearing will only be held when both parties consent to binding arbitration.  A party to arbitration shall include all persons who have executed consent to binding arbitration.  An application for fee arbitration may not be withdrawn when both parties have agreed to be bound by the results of the arbitration hearing unless both parties agree, in writing, to the withdrawal of the application.  Administrative Fee: Enclosed is a ______check/______money order in the amount of $________________ as payment of the fee for filing for fee arbitration. Payment must be made at the time of submitting the application for fee arbitration to the State Bar of Wisconsin. Please refer to Rule #33 of the enclosed procedural rules for the fee schedule structure. The fee structure relates to the amount in dispute, not the total amount of attorney fees. DO NOT SEND CASH.  You must answer all questions in the blank provided and you must attach copies of relevant documents such as contracts, correspondence or statements, and any additional information you consider relevant.  If you have any questions regarding this application or the fee arbitration process, please call the State Bar of Wisconsin, (800)728-7788; or (608) 257-3838. __________________________________ ________________________________ Case Number Date Received Updated: July 2009 2 APPLICATION AND RESPONSE FORM FOR FEE ARBITRATIONAnswer All Questions Please let us know how you heard about the Fee Arbitration Program: Office of Lawyer Regulation  A Lawyer  A Friend  The Internet  Other: (please explain)___________________________________________________________ Date: _______________________________ Applicant’s Name: ___________________________________________________________________ □ Client □ Attorney (check one) Address: ___________________________________________________________________________ (city) (state) (zip code) □ Home address or □ Business address (check one) Email Address: _______________________________________________________________________ Telephone Numbers: ( )____________________ Business ( )______________________ Cell ( )____________________ Respondent’s Name: _________________________________________________________________ □ Client □ Attorney (check one) Address: ___________________________________________________________________________ (city) (state) (zip code) □ Home address or □ Business address (check one) Email Address: _______________________________________________________________________ Telephone Number: ( ) ____________________ Business ( ) _______________________ Cell ( ) ____________________ Updated: July 2009 3 1. What is the total amount of attorney fees? (services only) ________________________________ How much of that amount is in dispute? ____________________________________________ 2. What was the total charge for disbursements? _________________________________________ How much of that amount is in dispute? ____________________________________________ 3. What is the total amount already paid to the attorney? __________________________________ 4. In what city or county were the legal services performed? ________________________________ 5. When were the legal services performed? _____________________________________________ 6. On what date did the fee dispute first arise? ___________________________________________ 7. For what type of legal services was the attorney employed? __________________________________________________________________________________ 8. Was there a written agreement or other correspondence on fees and disbursements for legal services? Yes ______ No______ If you answered "yes" please include a copy. 9. Was there an oral agreement in regards to legal fees and disbursements? Yes ______ No______If you answered "yes", please include a written explanation of what the oral agreement was. 10. On a separate sheet of paper , please state in DETAIL (1) the nature of the dispute, (2) the particulars of your position, and (3) all relevant dates. State the amount of attorney fees and disbursements that you feel are correct and the attorney fees and disbursements that you feel are in dispute. List your reasons. This is your opportunity to explain your side of the fee dispute. Please take advantage of it by being complete, yet concise, in answering this question. Attach additional sheets if more space is needed . 11. Do you agree to be bound by the result of the arbitration? Yes ________ No________ (NOTE: IF YOU DO NOT AGREE TO BE BOUND BY THE RESULTS OF THE ARBITRATION, JURISDICTION OF YOUR FEE DISPUTE CANNOT BE ACCEPTED AND YOUR APPLICATION WILL BE DENIED.) No party or party’s representative, panel member or person related to the program shall provide information on the arbitration to anyone not a party to the arbitration. The records, documents, files, proceedings, transcripts, notes, testimony and the arbitration decision shall not be made available to the public or to any person or body not involved in the dispute. The parties shall not disparage each other with respect to any matter arising in the arbitration. Updated: July 2009 4 All parties agree that members of the Fee Arbitration Committee, Panel, Program Administrator or program staff person shall have no liability for any official act or omission related to any arbitration under these rules.  By filing this application, I certify that the above information is true and correct. I certify that I have read the State Bar of Wisconsin's Committee on Resolution of Fee Disputes Rules as revised January 2009 for arbitration of fee disputes. Copies of the Rules are available at www.wisbar.org.  I further agree that a binding arbitration award in this matter shall include imposition of the statutory rate of interest on any portion of an award not paid within thirty (30) days of the date of the mailing of the Committee's decision to the parties, except as the parties may have otherwise previously contractual agreed. Date: ____________________ Your Signature _______________________________________