Settlement Proceeds Distribution Sheet

SETTLEMENT PROCEEDS DISTRIBUTION SHEET

CASE INFORMATION

Case Caption: [________________________________]

Client Name: [________________________________]

Date of Birth: [__/__/____]

SSN (Last 4): XXX-XX-[____]

Case Number: [________________________________]

Date of Incident: [__/__/____]

Attorney Name: [________________________________]

Firm Name: [________________________________]

Settlement Date: [__/__/____]

Prepared By: [________________________________]

Date Prepared: [__/__/____]

PART I: SETTLEMENT/RECOVERY INFORMATION

A. Settlement Details

Settlement Type:
☐ Pre-Litigation Settlement
☐ Post-Filing/Pre-Trial Settlement
☐ Mediation Settlement
☐ Arbitration Award
☐ Trial Verdict
☐ Appeal Settlement
☐ Structured Settlement
☐ Other: [________________________________]

Defendant/Paying Party: [________________________________]

Insurance Carrier: [________________________________]

Policy Number: [________________________________]

Claim Number: [________________________________]

B. Settlement Amount

C. Structured Settlement Components (if applicable)

☐ Lump Sum Payment: $[____]
☐ Periodic Payments:

• Amount: $[____] per ☐ month ☐ year
• Duration: [____] years
• Start Date: [__/__/____]
• Total Guaranteed: $[____]

Annuity Issuer: [________________________________]

Annuity Policy Number: [________________________________]

PART II: ATTORNEY FEES

A. Fee Agreement

Fee Type:
☐ Contingency Fee
☐ Hourly Fee
☐ Hybrid (Reduced hourly + contingency)
☐ Flat Fee
☐ Court-Awarded (Fee Shifting)

Fee Agreement Date: [__/__/____]

Fee Percentage (if contingency): [____]%

Fee Calculation Basis:
☐ Gross Settlement (before costs/liens)
☐ Net Settlement (after costs)
☐ Net Settlement (after costs and liens)
☐ Other: [________________________________]

B. Contingency Fee Calculation

Standard Contingency:

Applicable Stage: [________________________________]

Fee Calculation:

Gross Settlement: $[____] x [____]% = $[________________________________]

OR

(Gross Settlement - Costs): ($[____] - $[____]) x [____]% = $[________________________________]

C. Fee Adjustments

Sliding Scale (if applicable):

Statutory Fee Cap (if applicable):
☐ Workers' Compensation: [____]%
☐ Medical Malpractice: [____]%
☐ Social Security Disability: [____]%
☐ Other: [________________________________]

TOTAL ATTORNEY FEE: $[________________________________]

PART III: LITIGATION COSTS AND EXPENSES

A. Advanced Costs

TOTAL LITIGATION COSTS: $[________________________________]

B. Cost Recovery

Costs Paid From:
☐ Settlement proceeds (client responsibility per agreement)
☐ Attorney advanced, reimbursed from settlement
☐ Court-awarded costs
☐ Other: [________________________________]

PART IV: LIENS AND SUBROGATION

A. Lien Summary

TOTAL ORIGINAL LIENS: $[____]

TOTAL NEGOTIATED LIENS: $[________________________________]

TOTAL LIEN SAVINGS: $[________________________________]

B. Medicare Set-Aside (if applicable)

MSA Required: ☐ Yes ☐ No

MSA Amount: $[________________________________]

Funding Method: ☐ Lump Sum ☐ Annuity

PART V: UNPAID MEDICAL BILLS AND PROVIDER OBLIGATIONS

A. Outstanding Medical Bills

TOTAL UNPAID MEDICAL TO BE PAID: $[________________________________]

B. Letter of Protection Obligations

TOTAL LOP OBLIGATIONS: $[________________________________]

PART VI: CASE EXPENSES AND REIMBURSEMENTS

A. Client Advanced Expenses (to be reimbursed)

TOTAL CLIENT REIMBURSEMENT: $[________________________________]

B. Referral Fee (if applicable)

Referring Attorney: [________________________________]

Referral Agreement Date: [__/__/____]

Referral Fee Percentage: [____]% of attorney fee

Referral Fee Amount: $[________________________________]

Note: Referral fee is paid from attorney fee, not additional charge to client

PART VII: SETTLEMENT DISTRIBUTION CALCULATION

A. Full Distribution Summary

B. Detailed Distribution

PART VIII: TRUST ACCOUNT INFORMATION

A. Settlement Funds Receipt

Settlement Check/Wire Received: [__/__/____]

Amount Received: $[________________________________]

Payor: [________________________________]

Check Number (if applicable): [________________________________]

Deposited To:
Account Name: [________________________________]
Bank: [________________________________]
Account Number (Last 4): [____]
Date Deposited: [__/__/____]

B. Trust Account Reconciliation

PART IX: CLIENT ACKNOWLEDGMENT

A. Settlement Summary for Client

Your Settlement:

B. Client Signature

I, [________________________________], have reviewed this Settlement Distribution Sheet. I understand how my settlement proceeds have been distributed. I have had the opportunity to ask questions and have them answered to my satisfaction.

I acknowledge receipt of:
☐ Net settlement check in the amount of $[________________________________]
☐ Copy of this Settlement Distribution Sheet
☐ Copies of all lien satisfaction letters

Client Signature: _________________________________ Date: [__/__/____]

Client Printed Name: [________________________________]

PART X: DISBURSEMENT CHECKLIST

Pre-Disbursement

☐ Settlement agreement signed
☐ Release signed by client
☐ All liens identified and resolved or held
☐ Medicare final demand received and paid (within 60 days)
☐ All lien satisfaction letters received
☐ Fee agreement on file
☐ Distribution sheet reviewed with client
☐ Client questions answered

Disbursement

☐ Trust account properly funded
☐ All disbursement checks prepared
☐ Checks signed by authorized party
☐ Distribution documented
☐ Client check issued
☐ Client signed acknowledgment

Post-Disbursement

☐ Lien payments confirmed received
☐ Trust account reconciled to zero (for this matter)
☐ File copy of distribution sheet
☐ Closing letter to client
☐ File closed

ATTORNEY CERTIFICATION

I certify that this Settlement Distribution Sheet accurately reflects the distribution of settlement proceeds in accordance with the fee agreement, applicable liens, and professional responsibility rules.

Attorney Signature: _________________________________ Date: [__/__/____]

Attorney Name: [________________________________]

Bar Number: [________________________________]

NOTES

[________________________________]
[________________________________]
[________________________________]
[________________________________]

SOURCES AND REFERENCES

• State Rules of Professional Conduct (Trust Account Rules)
• State Bar Trust Account Handbook
• Medicare Secondary Payer Manual
• State lien priority statutes
• Fee agreement and case documents

This distribution sheet is for organizational and client communication purposes. Attorneys must comply with applicable professional responsibility rules regarding client funds, trust accounts, and disbursement procedures.