COURT COUNTY OFAPPLICATION FOR LUMP SUM PAYMENT OF ATTORNEY FEESThe Industrial Commissionof OhioIC-32-A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Mail this form to: Industrial Commission of Ohio Lump Sum Payments 30 W. Spring St. 5th floor Columbus, Ohio 43215Calendar No.CLAIM NUMBER SOCIAL SECURITY # DATE OF INJURYJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Fax: (614) 466-0514ADDRESS ON APPLICATION IS NEWEmployer's AddressInjured Worker's AddressPhone(NamePhone())CountyCountyCity, State, Zip Code AddressCity, State, Zip Code Name Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Employer's RepresentativeInjured Worker's RepresentativeNameNamePhone(Phone())AddressAddressCountyTHE PEOPLE OF THE STATE OF NEW YORK TOCountyCity, State, Zip CodeCity, State, Zip CodeThe undersigned attorney-at-law, duly authorized by the injured worker to represent him/her in the above captioned industrial claim, certifies that:(1) I have rendered the following services for this claim which were necessary to obtain the award for which the advancement to pay the fee is requested:GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County, (2) Should theApplication for Lump Sum Payment, now under consideration, be granted, the injured worker will not be liable for any further fee with respect to continuing compensation, except where a later dispute would arise in this claim, requiring my additional services. (3) Should theApplication for Lump Sum Payment include a request for reimbursement of expenses (not to exceed $500.00), a copy of the bill has been included with the application. Attorney's Signature (required)Date(Attorney must sign above and type name below)I, the undersigned injured worker, am making application for a lump sum advancement for payment of attorney fees in the amount of $. If the lump sum payment is granted by the Industrial Commission of Ohio, either wholly or in part, I request and authority is given to the Bureau of Workers' Compensation to distribute the lump sum payment directly to the person or persons to whom payment is now due from me, pursuant to any Commission order. This payment will result in a permanent reduction of weekly benefits from myAttorney(s) forDeath award which shall continue for the duration of the award.Permanent PartialPermanent TotalOffice and P.O. AddressI certify that the above facts on my application are true.Telephone No.: Facsimile No.: E-Mail Address:DateInjured Worker's Signature (required)Mobile Tel. No.:IC-32-AOIC 3022 (Rev 2/02)An Equal Opportunity Employer And Service ProviderAmerican LegalNet, Inc. www.USCourtForms.com
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