Form DC/AB1 "Request for Approval of Attorney's Fee" - Hawaii

What Is Form DC/AB1?

This is a legal form that was released by the Hawaii Department of Labor & Industrial Relations - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2012;
  • The latest edition provided by the Hawaii Department of Labor & Industrial Relations;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DC/AB1 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Labor & Industrial Relations.

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Download Form DC/AB1 "Request for Approval of Attorney's Fee" - Hawaii

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STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
AND
LABOR AND INDUSTRIAL RELATIONS APPEALS BOARD
REQUEST FOR APPROVAL OF ATTORNEY’S FEE
Notice is hereby given to the Director of Labor and Industrial Relations and/or the Labor and Industrial
Relations Appeals Board that the undersigned performed services as counsel in the following case for:
Claimant:
vs.
Employer:
DCD Case No.:
AB Case No.:
Attached is a statement itemizing the services provided for claimant(s), the time spent on each service (rounded to the
nearest one-tenth of an hour), and the costs advanced. Also attached are receipts documenting the costs advanced.
The itemized statement is summarized below:
DCD
Appeals Board
Attorney Hourly Rate: $
Per Hour
Attorney Hourly Rate: $
Per Hour
Attorney Total Hours
:
Hours
Attorney Total Hours:
Hours
Paralegal Hourly Rate: $
Per Hour
Paralegal Hourly Rate: $
Per Hour
Paralegal Total Hours:
Hours
Paralegal Total Hours:
Hours
Fee Requested: $
Fee Requested: $
Tax: $
Tax: $
Costs Requested: $
Costs Requested: $
DCD WC-17 Box # Requested:
Fees and Costs totaling $
are sought for the foregoing services, and approval thereof
is hereby requested in accordance with Chapter 386, Hawaii Revised Statutes. This request was served upon
on
as required pursuant to § 12-47-55 of the
Appeals Board’s Rules and/or § 12-10-69 of the Disability Compensation Division’s Rule. Any Party may file a
written objection to this request for approval no later than ten calendar days after service.
Required Attorney Information:
I have approximately
years’ experience in workers’ compensation cases.
I have participated in approximately
cases before the Disability Compensation Division over
the last 3 years.
I have participated in approximately
cases before the Labor and Industrial Relations Appeals
Board over the last 3 years.
I certify that the above information is submitted in good faith and is true and accurate to the best of my knowledge
and belief.
Signature:
Name (print):
Date:
Mailing Address:
City, State, ZIP:
DC/AB 1 (REV. 12/2012)
STATE OF HAWAII
DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DISABILITY COMPENSATION DIVISION
AND
LABOR AND INDUSTRIAL RELATIONS APPEALS BOARD
REQUEST FOR APPROVAL OF ATTORNEY’S FEE
Notice is hereby given to the Director of Labor and Industrial Relations and/or the Labor and Industrial
Relations Appeals Board that the undersigned performed services as counsel in the following case for:
Claimant:
vs.
Employer:
DCD Case No.:
AB Case No.:
Attached is a statement itemizing the services provided for claimant(s), the time spent on each service (rounded to the
nearest one-tenth of an hour), and the costs advanced. Also attached are receipts documenting the costs advanced.
The itemized statement is summarized below:
DCD
Appeals Board
Attorney Hourly Rate: $
Per Hour
Attorney Hourly Rate: $
Per Hour
Attorney Total Hours
:
Hours
Attorney Total Hours:
Hours
Paralegal Hourly Rate: $
Per Hour
Paralegal Hourly Rate: $
Per Hour
Paralegal Total Hours:
Hours
Paralegal Total Hours:
Hours
Fee Requested: $
Fee Requested: $
Tax: $
Tax: $
Costs Requested: $
Costs Requested: $
DCD WC-17 Box # Requested:
Fees and Costs totaling $
are sought for the foregoing services, and approval thereof
is hereby requested in accordance with Chapter 386, Hawaii Revised Statutes. This request was served upon
on
as required pursuant to § 12-47-55 of the
Appeals Board’s Rules and/or § 12-10-69 of the Disability Compensation Division’s Rule. Any Party may file a
written objection to this request for approval no later than ten calendar days after service.
Required Attorney Information:
I have approximately
years’ experience in workers’ compensation cases.
I have participated in approximately
cases before the Disability Compensation Division over
the last 3 years.
I have participated in approximately
cases before the Labor and Industrial Relations Appeals
Board over the last 3 years.
I certify that the above information is submitted in good faith and is true and accurate to the best of my knowledge
and belief.
Signature:
Name (print):
Date:
Mailing Address:
City, State, ZIP:
DC/AB 1 (REV. 12/2012)