"Settlement Disbursement Sheet Template"

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Settlement Disbursement Sheet
Attorney:
Claimant:
Law Firm:
Address:
Case No.
Date:
TOTAL SETTLEMENT:
$
LESS:
Attorney Fees
$
Legal Fees
$
Medical Reports
$
Police Reports
$
Office Fees (Calls/Mail)
$
Copies
$
Other:
$
NET DISBURSEMENT TO CLIENT:
$
I, the aforementioned claimant, hereby authorize my attorney and his/her personnel and staff to disburse
the monetary amount mentioned above according to the charges and distribution patterns provided. I
swear and attest that there are no further debts, liens, or encumbrances to the best of my knowledge.
Claimant
Date
Attorney
Date
Settlement Disbursement Sheet
Attorney:
Claimant:
Law Firm:
Address:
Case No.
Date:
TOTAL SETTLEMENT:
$
LESS:
Attorney Fees
$
Legal Fees
$
Medical Reports
$
Police Reports
$
Office Fees (Calls/Mail)
$
Copies
$
Other:
$
NET DISBURSEMENT TO CLIENT:
$
I, the aforementioned claimant, hereby authorize my attorney and his/her personnel and staff to disburse
the monetary amount mentioned above according to the charges and distribution patterns provided. I
swear and attest that there are no further debts, liens, or encumbrances to the best of my knowledge.
Claimant
Date
Attorney
Date
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