1a Current Settlement Payment 1b 70 Benefits Paid if any Total Redemption Settlement Amount ATTORNEY EXPENSES UNDER R408445 Total Expenses ATTORNEY FEE CALCULATION UNDER R408 ID: 898644
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1 WORKER’S SETTLEMENT STATEMENT Michi
WORKER’S SETTLEMENT STATEMENT Michigan Department of Licensing and Regulatory Affairs Workers’ Compensation Agency PO Box 30016, Lansing, MI 48909Defendant 1a. Current Settlement Payment $ 1b. 70% Benefits Paid (if any) $ Total Redemption Settlement Amount $ ATTORNEY EXPENSES UNDER R408.44(5) Total Expenses $ ATTORNEY FEE CALCULATION UNDER R408.44(3)(4)(7) 3a. Base for Fee Calculation (Total Redemption Minus Total Expenses) 3b. % of first $25,000=$ 3c. % above $25,000=$ 3d. % X =$ Total Attorney Fee $ Redemption Fee $ 100.00 DIRECT PAYMENTS 5a. $ 5b. $ 5c. $ Total Direct Payments $ 70% Benefits Paid $ Total Expenses, Attorney Fees, Redemption Fee, Direct Payments and 70% Benefits Net Amount to Plaintiff (1c minus 7) $ I certify that I have read and approved of this statement. Date Plaintiff Attorney for Plaintiff LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable to individuals with disabilities. Authority: Penalty: R408.44(3) Voluntary WC-544 (Rev. 5/12) Defendant WORKERÂ’S SETTLEMENT STATEMENT Michigan Department of L�D�E�R�U and �(�F�R�Q�R�P�L�F �2�S�S�R�U�W�X�Q�L�W�\ WorkersÂ’ �'�L�V�D�E�L�O�L�W�\�Compensation Agency PO Box 30016, Lansing, MI 48909 1a. Current Settlement Payment $ 1b. 70% Benefits Paid (if any) $ Total Redemption Settlement Amount $ ATTORNEY EXPENSES UNDER R408.44(5) Total Expenses $ ATTORNEY FEE CALCULATION UNDER R408.44(3)(4)(7) 3a. Base for Fee Calculation (Total Redemption Minus Total Expenses) 3b. % of first $25,000=$ 3c. % above $25,000=$ 3d. % X =$ Total Attorney Fee $ Redemption Fee $ 100.00 DIRECT PAYMENTS 5a. $ 5b. $ 5c. $ Total Direct Payments $ 70% Benefits Paid $ Total Expenses, Attorney Fees, Redemption Fee, Direct Payments and 70% Benefits Net Amount to Plaintiff (1c minus 7) $ I certify that I have read and approved of this statement. Plaintiff Attorney for Plaintiff Authority: Penalty: R408.44(3) Voluntary �(�2 is an equal opportunity employer/program. Auxiliary aids, services and other reasonable �accommodations are available upon request to individuals with disabilities. WC-544 (Rev. �/1� )