Fill and Sign the In Re Washington Public Power Supply Sys Sec Lit 779 F Form

SETTLEMENT STATEMENT Client:___________________________________ Date:00/00/00Gross Settlement: $________Attorney 45% plus expenses Outstanding Expenses:Court Costs:$ 00.00Long Distance/Fax:$ 0.00Copying/Postage:$ 000.00Investigation:$ 000.00Legal Research:$ 000.00Experts: $ 0.00Travel/Mileage: $ 00.00 Client’s Share of Infinity General Expenses (WaivedPer Agreement) $ 0.00Total Expenses: $ 0,000.00Net Amount of Settlement $ 000.00 Attorney’s Fee (45% of Net Settlement Waived): $ 0.00Total Fees & Expenses: $0,000.00Client’s (Net) Share of Recovery: $0,000.00______________________________________________________________________________ ______________We declare that we have read and do understand this Settlement Statement. The deductions for attorney fees and expenses have been explained to us and are reasonable and approved by us. The amount of our recovery was a matter of compromise between us and the law firm of ____________________________ and we have made this agreement with the advice of our own, separate counsel. We understand, agree and declare that: (1) It has been explained to us that there may be tax consequences that apply to this settlement and that it is our responsibility to determine and to pay the appropriate amount of taxes, if any, owed to the government; (2) It has been explained to us that our file will be retained by the attorneys at ____________________________, P.C., for five years and at the end of that time, it will be destroyed. We have been given the opportunity to obtain from our file all documents to which we are entitled. We authorize said law firm to destroy our file after five years without giving any notice to us of that fact.Approved: ClientDate: ___________________________ Approved: ClientDate: ____________________________