Closing Statement and Disbursement

NOTE TO PRACTITIONER
This is a settlement-accounting and authorization worksheet. A category label
does not prove that a lien, reimbursement right, assignment, letter of protection,
hold, set-aside, tax, fee, cost, or payment obligation exists. Verify each asserted
interest and the governing trust-account rule. Do not disburse disputed or
restricted funds merely because the client signs a closing statement, and do not
force a matter ledger to zero while a proper hold remains.

CLOSING STATEMENT AND DISBURSEMENT WORKSHEET

1. Matter and Disbursement Profile

1.1 Client and matter

• Client(s) and capacity: [NAME / ADULT / MINOR / ESTATE / GUARDIAN / OTHER]
• Matter and file number: [DETAILS]
• Responsible lawyer and firm entity: [DETAILS]
• Settlement / judgment date: [DATE]
• Release, order, approval, and dismissal status: [DETAILS]

• Court, probate, guardianship, bankruptcy, workers' compensation, agency, or
  structured-settlement approval required: [DETAILS / NONE]

• Client identity and payment instructions verified by: [METHOD / DATE / PERSON]

Do not place a full Social Security number, bank credential, or unnecessary medical
identifier on the client-facing statement. Store sensitive data in the approved system.

1.2 Rules and instruments checked

2. Settlement Proceeds Received

• ☐ Payer, payee names, releases, endorsements, and settlement conditions matched
• ☐ Trust / client-funds account selected under the governing rules
• ☐ Collection or availability confirmed before dependent disbursements
• ☐ Returned-payment, chargeback, rescission, appeal, or approval risk addressed
• ☐ Each co-client, derivative claimant, assignee, or allocation issue resolved

3. Attorney Fee Calculation

3.1 Fee basis

• Fee agreement date and version: [DATE / ATTACHMENT]
• Client(s) who signed and capacity: [DETAILS]

• Calculation base: ☐ Gross proceeds ☐ Net after selected costs ☐ Tiered event
  ☐ Court / agency schedule ☐ Other: [EXACT TERM]

• Applicable percentage(s), event(s), and cap(s): [DETAILS]

• Prior fees, fee sharing, co-counsel, referral, or court approval: [DETAILS]
• Statutory, court, insurer, defendant, or separate fee recovery: [DETAILS]

3.2 Calculation

Confirm that the agreement, governing professional rules, required client consent,
and any tribunal approval permit the fee and division. Do not describe a calculation
as approved merely because the client signs this worksheet.

4. Costs and Expenses

• ☐ Duplicate, unrelated, written-off, overhead, interest, and tax items reviewed
• ☐ Gross-versus-net fee sequence matches the fee agreement and governing rules
• ☐ Client received the required itemization and supporting-document access
• ☐ Refunds, vendor credits, and unused advances credited to the correct matter

5. Asserted Third-Party Interests and Holds

5.1 Interest status legend

Use one status for each item:

• Claimed: a person asserts payment, but validity / amount is unresolved.

• Verified: counsel confirmed the legal / contractual basis, debtor, scope,
  priority, notice, perfection or preservation requirement, and amount method.

• Agreed: authorized parties signed a resolution or payment instruction.

• Ordered: a tribunal or agency directed the treatment.

• Disputed / held: all or part must remain in trust or another approved account
  pending resolution under the selected rules.

• Rejected / released: the asserted interest was withdrawn, released, expired,
  adjudicated, or determined inapplicable, with evidence retained.

5.2 Interest ledger

Screen, as applicable, for government benefit programs, health or welfare plans,
workers' compensation, hospitals and providers, letters of protection, child or
family support, taxes, bankruptcy, litigation funding, assignments, attorneys,
guardians, estates, insurers, and other claimants. The screen does not concede that
any category creates a lien or reimbursement right.

5.3 Government and benefit-program review

• Program / agency and beneficiary status dates: [DETAILS]

• Notice, portal, authorization, conditional-payment, final-demand, appeal, waiver,
  allocation, procurement-cost, and payment steps actually required: [DETAILS]

• Final amount and evidence: [DETAILS]

• Future-care, set-aside, reporting, or administration analysis: [DETAILS]

Do not create or fund a Medicare or other set-aside merely because this template
contains a field. Record the governing authority, approval, allocation, funding,
administration, and client advice if a set-aside is actually selected.

5.4 Disputed funds plan

• Dispute and parties notified: [DETAILS]
• Undisputed portion released under selected rule: [DETAILS]
• Amount retained and account / subledger: $[AMOUNT] / [DETAILS]

• Written agreement, interpleader, arbitration, court, agency, or other resolution
  route: [DETAILS]

• Review date and responsible lawyer: [DATE / NAME]

6. Tax, Structured Settlement, and Payment Method

6.1 Tax and reporting profile

• Settlement allocation and controlling documents: [DETAILS]
• Payer reporting forms or withholding: [DETAILS]
• Attorney / firm reporting and taxpayer information: [DETAILS]

• Interest, wages, fees, punitive, property, confidentiality, or other components:
  [DETAILS]

• Independent tax advice obtained / offered: [DETAILS]

The client acknowledgment should state what advice was and was not provided. Do not
state that a component is taxable or nontaxable without current, fact-specific advice.

6.2 Structured, restricted, or protected payment

• Structure / annuity / trust / blocked account / guardianship vehicle: [DETAILS]
• Owner, obligor, assignee, issuer, trustee, custodian, or administrator: [DETAILS]
• Court / agency approval and qualified assignment or other analysis: [DETAILS]
• Payment schedule, fees, investment limits, beneficiary, and tax advice: [DETAILS]

6.3 Client payment instructions

• Payee legal name and capacity: [DETAILS]

• Method: ☐ Trust-account check ☐ Verified wire ☐ ACH ☐ Protected account
  ☐ Structure / annuity ☐ Other approved method: [DETAILS]

• Independent verification method and date: [DETAILS]

• Split, multiple-client, estate, guardian, or attorney-in-fact authority: [DETAILS]
• Fraud-warning and change-of-instructions process completed: ☐ Yes

7. Proposed Distribution Statement

Control total: Gross proceeds plus other receipts must equal all fees, costs,
payments, holds, protected funding, and client distributions. Difference: $[0.00].

If a hold remains, the matter subledger ending balance should equal the proper hold;
it should not be forced to zero.

8. Disbursement Authorization and Register

8.1 Proposed disbursements

8.2 Approval controls

• ☐ Trust receipt collected / available status confirmed
• ☐ Fee and cost calculation independently reviewed
• ☐ Every third-party payment or hold has documented authority
• ☐ Client allocation and payee authority confirmed
• ☐ Court / agency / guardian / estate / bankruptcy approval satisfied
• ☐ Payment instructions independently verified
• ☐ Required dual approval and bank control completed
• ☐ No unresolved discrepancy in the control total

8.3 Issued-payment register

9. Client Review and Direction

I, [CLIENT NAME AND CAPACITY], acknowledge that:

• ☐ I received and reviewed this itemized statement and had an opportunity to ask questions.
• ☐ The gross proceeds listed are: [CONFIRMED / DISPUTED AS FOLLOWS].
• ☐ The attorney-fee and cost entries match my understanding of the identified fee agreement, subject to any issue stated here: [DETAILS].
• ☐ The third-party claims, agreed payments, and retained amounts were explained to me, including unresolved items: [DETAILS].
• ☐ I authorize the proposed payments and holds listed in Section 8, except: [DETAILS].
• ☐ I approve payment of the currently distributable amount by the verified method in Section 6.3.
• ☐ The firm explained the scope of tax advice actually provided and recommended independent advice where appropriate.
• ☐ The firm explained any remaining approval, structure, set-aside, lien, reimbursement, or disputed-funds process.

This acknowledgment does not validate an unlawful fee or disbursement, waive a
nonwaivable right, resolve a third party's claim, supply missing authority, or by
itself terminate the attorney-client relationship. Any client indemnity must be a
separately reviewed, specifically authorized provision; none is supplied here.

Client / authorized representative

Signature: ______________________________

Name and capacity: [DETAILS]

Date: [DATE]

Lawyer review

Signature: ______________________________

Name: [DETAILS]

Date: [DATE]

10. Matter Subledger and Reconciliation

• Matter receipts: $[AMOUNT]
• Matter disbursements: $[AMOUNT]
• Matter ending balance: $[AMOUNT]
• Proper unresolved hold / uncleared item: $[AMOUNT]
• Unexplained difference: $[0.00]
• Client / matter ledger agrees with bank and reconciliation records: ☐ Yes
• Reviewer and date: [NAME / DATE]

Do not mark the trust account itself “fully reconciled” from one matter worksheet.
Complete the separate bank-wide reconciliation and individual client-ledger process
required by the firm's governing trust-account rules.

11. Remaining Items and File Closing

11.1 Open items

11.2 Closing communication

• Scope completed and any excluded / continuing work: [DETAILS]
• Remaining deadlines or client responsibilities: [DETAILS]
• Original documents and property returned: [DETAILS]
• File-copy access, retention, destruction, and contact policy: [DETAILS]
• Trust balance, holds, unclaimed funds, and later receipts: [DETAILS]
• Separate closing / disengagement letter sent: [DATE / METHOD]

A disbursement statement is not a substitute for any closing notice required by the
engagement, governing professional rules, or circumstances.

12. Attachment Index

• ☐ Settlement, release, judgment, approval, and dismissal documents
• ☐ Fee agreement, amendments, client consents, and fee-division documents
• ☐ Cost invoices, receipts, refunds, and write-off record

• ☐ Third-party claim notices, authority analysis, final demands, resolutions,
  releases, payment instructions, and proof of payment

• ☐ Government-program correspondence and portal confirmations

• ☐ Tax, allocation, structure, set-aside, trust, or protected-account documents
• ☐ Client authorization and verified payment instructions
• ☐ Deposit, collection, check, transfer, and cleared-payment evidence
• ☐ Matter ledger, bank references, and reconciliation review
• ☐ Closing communication and file-property record

13. Final Compliance Check

• ☐ Every fee and cost matches the agreement and current governing rules
• ☐ Every asserted interest classified rather than assumed to be a lien
• ☐ Undisputed and disputed funds treated under the selected trust rules
• ☐ No disbursement preceded collection, approval, or verified instructions
• ☐ Minor, estate, bankruptcy, guardianship, structure, and benefit issues resolved
• ☐ Tax status not promised without fact-specific advice
• ☐ No broad client indemnity or automatic relationship-termination clause
• ☐ Matter balance equals proper holds and uncleared items, not an artificial zero
• ☐ Client received the required accounting and copies
• ☐ Bank-wide and matter-level reconciliations completed separately
• ☐ Qualified counsel and authorized accounting personnel approved release