Fill and Sign the Personal Injury Settlement Statement Form

- 1 - SETTLEMENT STATEMENT Client: Date: Gross Settlement: $ Attorney Fee: $ Outstanding Expenses: Court Costs: $ Long Distance/Fax: $ Copying/Postage: $ Investigation: $ Legal Research: $ Experts: $ Travel/Mileage: $ Medical Records: $ Depositions: $ Client Advances: $ Total Expenses: $ Medical Liens (See Exhibit A): $ Total Fee, Expenses and Med Liens: $ Client’s (Net) Share of Recovery: $ Of the above amounts, the following will be paid to the attorney referring your case: 1/3 of the Gross Attorney’s Fee to: Referring Attorney Expenses: $ The remainder of the fee and expenses will be paid to _______________ & Associates, P.C. I declare that this Settlement Statement has been read and is understood and that the deductions for attorney’s fees, cost advances, expenses, and other items shown above are reasonable and approved by me. I understand, agree and declare that; (1) It is my personal responsibility and obligation to pay all past and future medical and hospital bills incurred by me or on my behalf except those specific amounts which are noted above and to reimburse any insurance company who may have a subrogated interest, unless such interest is set out above; (2) The firm of ____________________________, P.C., and its attorneys have no responsibility to pay my medical or hospital bills except those charges which are - 2 - specifically itemized above; (3) It has been explained to me that my file will be retained by the attorneys at ____________________________, P.C., for five years and at the end of that time, it will be destroyed. I have been given the opportunity to obtain from my files all documents to which I am entitled. I authorize said law firm to destroy my file after five years without giving any notice to me of that fact. Approved: ____________________________ Date: __________________________