Closing Statement and Disbursement

CLOSING STATEMENT AND DISBURSEMENT SHEET

Personal Injury Settlement Accounting

SECTION 1: CASE INFORMATION

A. Client Information

Client Name: [________________________________]
Address: [________________________________]
City, State, Zip: [________________________________]
Phone: [________________________________]
Email: [________________________________]
Social Security Number: [________________________________]

B. Case Information

File Number: [________________________________]
Date of Incident: [________________________________]
Date Case Opened: [________________________________]
Date Case Closed: [________________________________]
Responsible Attorney: [________________________________]

C. Defendant/Insurance Information

Defendant: [________________________________]
Insurance Company: [________________________________]
Claim Number: [________________________________]
Adjuster: [________________________________]

SECTION 2: SETTLEMENT RECEIPT

A. Settlement Amount

B. Settlement Funds Received

☐ Check received on: [________________________________]
☐ Wire transfer received on: [________________________________]
☐ Deposited to trust account on: [________________________________]
☐ Check cleared on: [________________________________]

Trust Account: [________________________________]
Bank: [________________________________]

SECTION 3: ATTORNEY FEES

A. Fee Calculation

Fee Agreement:
☐ Contingency Fee: [____]% of gross recovery
☐ Sliding Scale: [____]% pre-suit / [____]% post-suit
☐ Other: [________________________________]

Fee Calculation:

B. Fee Disclosure

The attorney fee of $[____________] represents [____]% of the gross settlement of $[____________].

SECTION 4: COSTS AND EXPENSES

A. Itemized Costs

B. Costs Summary

SECTION 5: LIEN PAYMENTS

A. Medicare/Medicaid

Medicare Final Demand Obtained: ☐ Yes ☐ N/A
Date: [________________________________]

B. Health Insurance Subrogation

C. Hospital/Medical Provider Liens

D. Letters of Protection

E. Workers' Compensation Lien

F. Government Liens

G. Other Liens/Payments

H. Medicare Set-Aside (if applicable)

I. Total Liens Summary

SECTION 6: DISBURSEMENT SUMMARY

A. Settlement Accounting

B. Percentage Analysis

SECTION 7: DISBURSEMENT SCHEDULE

A. Checks to be Issued

B. Disbursement Verification

SECTION 8: CLIENT ACKNOWLEDGMENT

A. Client Representations

I, [CLIENT NAME], acknowledge and represent:

☐ I have reviewed this Closing Statement and Disbursement Sheet.

☐ I understand the calculation of attorney fees and costs.

☐ I understand and approve all lien payments listed herein.

☐ I confirm that I have disclosed all health insurance, Medicare, Medicaid, and other liens that may apply to this settlement.

☐ I understand that I am receiving $[____________] as my net settlement.

☐ I understand the Medicare Set-Aside requirements (if applicable).

☐ I have received copies of all settlement documents.

☐ I authorize [LAW FIRM] to make the disbursements listed above.

B. Tax Acknowledgment

☐ I understand that [LAW FIRM] has not provided tax advice regarding this settlement.

☐ I have been advised to consult with a tax professional regarding the tax treatment of this settlement.

☐ I understand that certain components of this settlement may be taxable.

C. Lien Indemnification

☐ I agree to indemnify [LAW FIRM] against any claims by Medicare, Medicaid, health insurers, or other parties claiming a right to payment from this settlement that were not disclosed to [LAW FIRM].

D. Final Acknowledgment

☐ I am satisfied with the representation provided by [LAW FIRM] in this matter.

☐ I confirm this matter is concluded and the attorney-client relationship is terminated for this matter.

SECTION 9: SIGNATURES

Client Signature

I have read and approve this Closing Statement and Disbursement Sheet.

Client Signature: _________________________________ Date: ______________

Printed Name: _________________________________

Co-Client Signature (if applicable)

Client Signature: _________________________________ Date: ______________

Printed Name: _________________________________

Attorney Signature

I certify that this Closing Statement accurately reflects the settlement, fees, costs, and disbursements in this matter.

Attorney Signature: _________________________________ Date: ______________

Printed Name: _________________________________

State Bar Number: _________________________________

SECTION 10: DISTRIBUTION NOTES

A. Special Instructions

[Note any special distribution instructions]

☐ Client pickup: Date: [________________]
☐ Mail to client: Address: [________________________________]
☐ Wire transfer: Account: [________________________________]
☐ Direct deposit: [________________________________]
☐ Other: [________________________________]

B. Outstanding Issues

☐ None

☐ Outstanding issues:
[________________________________]
[________________________________]

C. File Retention

☐ Client advised of file retention policy
☐ Client provided copies of key documents
☐ File closed and archived: [DATE]

SECTION 11: LIEN SAVINGS ANALYSIS

Lien negotiation saved client: $[________________________________]

SECTION 12: TRUST ACCOUNT RECONCILIATION

A. Trust Account Activity

B. Reconciliation

Beginning Balance: $[________________________________]
Plus: Deposits: $[________________________________]
Less: Disbursements: $[________________________________]
Ending Balance: $0.00

☐ Trust account fully reconciled
☐ All funds properly disbursed

SECTION 13: ATTACHMENTS

☐ Attachment A: Copies of all lien satisfaction letters
☐ Attachment B: Medicare Final Demand Letter
☐ Attachment C: Fee Agreement
☐ Attachment D: Settlement Agreement/Release
☐ Attachment E: Itemized cost receipts
☐ Attachment F: MSA documents (if applicable)
☐ Attachment G: Trust account ledger

OFFICE USE ONLY