Form MN PT03 "Petition for Taxation of Actual and Necessary Disbursements" - Minnesota

What Is Form MN PT03?

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

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Minnesota Department of Labor and Industry;
  • 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 MN PT03 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Labor and Industry.

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Download Form MN PT03 "Petition for Taxation of Actual and Necessary Disbursements" - Minnesota

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WID or SSN
Office of Administrative Hearings
Workers’ Compensation Division
PO Box 64620
PT 0 3
DATE(S) OF CLAIMED INJURY
St. Paul, MN 55164-0620
(651) 361-7900
DO NOT USE THIS SPACE
EMPLOYEE
VS.
Petition for Taxation of Actual
EMPLOYER
and Necessary Disbursements
AND
Before:
Compensation Judge
INSURER
Court of Appeals
AND
See Note on reverse side before drafting.
PRINT IN INK or TYPE
ENTER DATES in MM/DD/YYYY FORMAT
PLEASE TAKE NOTICE that the following Bill of Actual and Necessary Disbursements with proof of service on you, will be filed at the
Office of Administrative Hearings, PO Box 64620, St. Paul, Minnesota, 55164-0620, for taxation and allowance in favor of the applicant.
YOU WILL FURTHER TAKE NOTICE that pursuant to the Workers’ Compensation Rules you have ten days from the date of service
hereof in which to serve and file any objection to said taxation and allowance with admission or proof of service upon the other parties.
Unless you request an opportunity to personally appear to oppose said taxation and allowance, the Court of Appeals or Compensation Judge
will consider said petition and any objection thereto based solely on the files, records and proceedings herein and will issue an order thereon.
Dated this
day of
By
Attorney for
BILL OF ACTUAL AND NECESSARY DISBURSEMENTS
WITNESS FEES
Miles
Name
Residence
Days and Dates
Traveled
AMOUNT
$
$
$
$
OTHER DISBURSEMENTS State other disbursements, in detail, giving the facts and circumstances showing the necessity and
reasonableness of each item, including expert witness fees, attorney fees, or any unusual disbursements, or support such items by separate
affidavits.)
$
$
$
$
$
$
TOTAL DISBURSEMENTS $
MN PT03 (6/18)
(over)
Reset
WID or SSN
Office of Administrative Hearings
Workers’ Compensation Division
PO Box 64620
PT 0 3
DATE(S) OF CLAIMED INJURY
St. Paul, MN 55164-0620
(651) 361-7900
DO NOT USE THIS SPACE
EMPLOYEE
VS.
Petition for Taxation of Actual
EMPLOYER
and Necessary Disbursements
AND
Before:
Compensation Judge
INSURER
Court of Appeals
AND
See Note on reverse side before drafting.
PRINT IN INK or TYPE
ENTER DATES in MM/DD/YYYY FORMAT
PLEASE TAKE NOTICE that the following Bill of Actual and Necessary Disbursements with proof of service on you, will be filed at the
Office of Administrative Hearings, PO Box 64620, St. Paul, Minnesota, 55164-0620, for taxation and allowance in favor of the applicant.
YOU WILL FURTHER TAKE NOTICE that pursuant to the Workers’ Compensation Rules you have ten days from the date of service
hereof in which to serve and file any objection to said taxation and allowance with admission or proof of service upon the other parties.
Unless you request an opportunity to personally appear to oppose said taxation and allowance, the Court of Appeals or Compensation Judge
will consider said petition and any objection thereto based solely on the files, records and proceedings herein and will issue an order thereon.
Dated this
day of
By
Attorney for
BILL OF ACTUAL AND NECESSARY DISBURSEMENTS
WITNESS FEES
Miles
Name
Residence
Days and Dates
Traveled
AMOUNT
$
$
$
$
OTHER DISBURSEMENTS State other disbursements, in detail, giving the facts and circumstances showing the necessity and
reasonableness of each item, including expert witness fees, attorney fees, or any unusual disbursements, or support such items by separate
affidavits.)
$
$
$
$
$
$
TOTAL DISBURSEMENTS $
MN PT03 (6/18)
(over)
STATE OF MINNESOTA
}
}
ss.
VERIFICATION
COUNTY OF
}
I,
, being duly sworn, state that I am an attorney representing the prevailing
party,
, in the foregoing matter; that the same is a true and correct statement of the
actual and necessary disbursements of
in said matter, and that all the items thereof
have been actually and necessarily paid or incurred therein by or on behalf of said
, as
more fully appears by additional affidavits hereto attached, marked Exhibits
respectively;
and that each of the witnesses was a necessary witness for the
at the hearing, and each
necessarily traveled the number of miles set opposite their name in going from their place of residence to the place of hearing and returning
therefrom, and that each necessarily attended the hearing the number of days set opposite their name.
Subscribed and sworn to before me
Signature
this
day of
Notary Public
My Commission expires
STATE OF MINNESOTA
}
}
ss.
AFFIDAVIT OF SERVICE
COUNTY OF
}
I,
, being first duly sworn, state that on
, I
served a true and correct copy of this document, enclosed in a properly addressed envelope, by depositing the same, with postage prepaid,
in the United States mail at
, Minnesota, addressed as follows:
NAMES AND ADDRESSES
Subscribed and sworn to before me
Signature
this
day of
Notary Public
My Commission expires
ATTORNEYS PLEASE NOTE
1.
When a case has been heard by a compensation judge and no appeal has been taken from the decision within the time allowed by statute,
taxation of all disbursements is made by the compensation judge.
When a case has been heard by a compensation judge and thereafter appealed to the Workers’ Compensation Court of Appeals, taxation
2.
of all disbursements is made by the Court of Appeals, including those incurred at the hearing before the compensation judge and the Court
of Appeals.
3.
The opposing party has ten days from the date of service in which to serve and file, with admission or proof of service, a formal objection to
taxation or allowance.
4.
If required, a time for hearing before the compensation judge or Court of Appeals will be fixed by the Court of Appeals and notice thereof
given to the parties.
5.
Pursuant to M.S. § 176.511, reasonable attorney fees may be allowed if not allowed in the award by the Court of Appeals.
This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-
342-5354.
ANY PERSON WHO, WITH INTENT TO DEFRAUD, RECEIVES WORKERS’ COMPENSATION BENEFITS TO WHICH THE PERSON IS NOT ENTITLED BY
KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED
PURSUANT TO SECTION 609.52, SUBDIVISION 3.
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