Excess Fee Exhibit {PF04}

MN PF04 (6/18) (over) Office of Administrative Hearings PO Box 64620 St. Paul, MN 55164 - 0620 (651) 361 - 7900 Excess Fee Exhibit (File this in addition to the Statement of Attorney Fees, if applicable.) PRINT IN INK or TYPE ENTER DATES in MM/DD/YYYY FORMAT DO NOT USE THIS SPACE WID or SSN DATE(S) OF CLAIMED INJURY EMPLOYEE VS. EMPLOYER(S) AND INSURER(S) AND I am the attorney for the employee, and I certify that the following statements are true: 1. The specific legal service(s) performed, the date(s) performed, and the number of hours spent for each service in representin g the (date) are: Attached to this Exhibit; or As follows: 2. I have the following experience and 3. The following is a description of the factual and legal issues in dispute: 4. The nature of proof required in this case and the responsibility assumed by me was as follows: American LegalNet, Inc. www.FormsWorkFlow.com 5. The following additional information should be considered in determining attorney fees: 6. At this time a hearing on the matter of attorney fees is is not requested. If a hearing is held, specify the language/dialect of any needed interpreter: If a reasonable accommodation of disability is requested for a hearing, describe: ATTORNEY FOR EMPLOYEE ATTORNEY FOR EMPLOYEE SIGNATURE ADDRESS ATTORNEY REGISTRATION NUMBER CITY STATE ZIP CODE TELEPHONE NUMBER This material can be made available in different forms, such as large print, Braille or audio. To request, call (651) 284-5032 or 1-800-342-5354. NTITLED BY KNOWINGLY MISREPRESENTING, MISSTATING, OR FAILING TO DISCLOSE ANY MATERIAL FACT IS GUILTY OF THEFT AND SHALL BE SENTENCED PURSUANT TO SECTION 609.52, SUBDIVISION 3. American LegalNet, Inc. www.FormsWorkFlow.com