Closing Statement and Disbursement

Closing Statement and Disbursement

Before you use this: This statement records a particular settlement and proposed or completed disbursements. Confirm that each claimed interest is actually payable, that disputed sums are held as required by the governing rule or order, and that the matter ledger reconciles without forcing a zero balance.

1. Funds received

Funds expected but not received are [AMOUNT, SOURCE, STATUS OR "NONE"]. They are excluded from (A) and from the distributable balance. Any court or third-party approval needed before use of funds is [AUTHORITY, STATUS, AND RECORD OR "NONE"].

2. Fee and expense accounting

The fee base is [GROSS/NET/OTHER UNDER AGREEMENT], and the calculation is [SHOW ARITHMETIC]. Costs were [DEDUCTED BEFORE/AFTER FEE] as the agreement requires. Prior advances, payments, refunds, or credits are [ITEMIZATION]. A disputed fee remains in the held column pending [IDENTIFIED RESOLUTION PROCESS]; client acknowledgment below does not settle a dispute by itself.

3. Other claimed interests and holds

The above may include a Medicare or Medicaid recovery claim, health-plan reimbursement, provider claim, workers' compensation interest, child support order, or other interest only when actually asserted and reviewed. A provider bill or insurance payment is not entered as a payable lien merely because it exists. The decision for each line is documented by [FINAL DEMAND, RESOLUTION, COURT ORDER, CLIENT INSTRUCTION, OR OTHER RECORD]. Any future medical allocation, tax reporting, or benefit issue is [SEPARATELY REVIEWED RESULT OR "UNRESOLVED—NO DISTRIBUTION AUTHORIZED FROM THE HELD AMOUNT"].

4. Matter reconciliation

The amount (E) is held for [IDENTIFIED FEE/THIRD-PARTY DISPUTE, UNCLEARED ITEM, COURT ORDER, FUTURE EXPENSE, OR OTHER BASIS], with next review date [__/__/____]. If (E) is zero, the ledger and proof support that result as of [DATE]; this form does not require a zero balance. This is a matter ledger reconciliation, not a reconciliation of the firm's entire trust bank account.

5. Payment instructions and proof

Total payments issued or authorized: $[AMOUNT]. Outstanding approved but unpaid items are [LIST AND AMOUNT]. No account number, Social Security number, or unnecessary medical detail is included on this client-facing copy.

6. Client review and signatures

I received this closing statement and the supporting itemization listed below. I understand the amount proposed or paid to me, the amounts currently held, and whom to contact about a disputed item. My signature records review and the selected payment instructions; it is not a release of malpractice claims, indemnity for an undisclosed claimant, approval of an unresolved lien, or termination of representation.

Client payment instruction or correction: [INSTRUCTION, SECURE DESTINATION CONFIRMATION, OR DISPUTE].

Client signature: ______________________________ Date: [__/__/____]

Client printed name: [NAME]

Attorney or authorized preparer signature: ______________________________ Date: [__/__/____]

Name and role: [NAME AND ROLE]

Supporting records provided or available securely: [FEE AGREEMENT, COST ITEMIZATION, CLAIM RESOLUTIONS, PAYMENT RECEIPTS, MATTER LEDGER, OR OTHER].

Next accounting or hold review date: [__/__/____ / NONE]