BHBA: Form F

Beverly Hills Bar Association, 300 S. Beverly Drive, Suite 201, Beverly Hills, CA 90212 310.553.6644

1. Petitioner’s Name: (1)

Petitioner’s Name: (2)

Address:

City:                                                                        State:                             Zip Code:

Telephone: (      )                                                                Fax: (      )

2. Client(s) with whom you are having the dispute:

Name:

Address:

City:                                                                        State:                             Zip Code:

Telephone: (      )                                                                Fax: (      )

3. Attorney representing you in this dispute, if applicable:

Name:

Address:

City:                                                                        State:                             Zip Code:

Telephone: (      )                                                                Fax: (      )

4. ***IMPORTANT*** You must give a detailed written description of the fee dispute on a separate sheet of paper. Submit a total of one original and four copies of this Request form for a grand total of five. Each of the five Request forms should have any and all additional information attached. DO NOT send originals of attachments.

5. What type of case resulted in the fee dispute? For example: family, immigration, etc. _____________________________

6. (A) Do you have a written fee agreement?                                                               Yes /    /      No /    /
If yes, attach a copy. If no, explain your verbal agreement on separate sheet.

(B) If yes, do you have an arbitration clause in the agreement:                                  Yes /    /      No /    /
[If you do have an arbitration clause in your fee agreement, please read Rule 4.A.]

7. (A) Was your fee arrangement:                                                           Hourly /    /      or Contingent /    /
(B) If contingent, is the matter concluded?                                                                    Yes /    /      No /    /
(C) Are you the client’s:                                              First attorney? /    /      or Successor attorney? /    /

8. In accordance with Business and Professions code 6203(d), who is the responsible attorney?

Name:

9. Unless both sides agree to BINDING ARBITRATION, the arbitration will be non-binding

You Must Choose One:                                                                            Binding /    /      Non-Binding /    /

10. Amount in dispute:

A) What is the total amount of the costs/fees charge to client?                                    $______________

B) How much have you already been paid?                                                                   $______________

C) What is the outstanding balance?                                                                              $______________

11. Filing Fees: The filing fee must be paid at the time of filing and is based on the amount in dispute. Refer to Rules of Procedure #13, regarding possible additional fees/costs.

/    / If the amount in dispute is less than $10,000 you pay 5% of that amount. Amount enclosed:                                                                                                                            $____________
/    / Or, if the amount in dispute is more than $10,000, you pay 7% of that amount. Amount enclosed:                                                                                                                             $____________

12. If you choose BINDING ARBITRATION and the total amount in dispute is over $10,000 or NON-BINDING and your case is over $20,000 in dispute, it may be heard by a 3-arbitrator panel. However, if you both agree, it may still be heard by one arbitrator. NOTE: if the matter does not qualify for three, one arbitrator will always be assigned.
PLEASE CHECK ONE:                             THREE ARBITRATORS /    /      ONE ARBITRATOR /    /

13. If you both agree, you are also entitled to up to four hours of mediation time. If the matter does not resolve through mediation it will then proceed to arbitration. Please refer to the Mediation Rules of Procedure. Indicate your choice:
/    / I WOULD LIKE TO TRY MEDIATION. /    / I DO NOT WANT TO MEDIATE THIS DISPUTE.

14. I acknowledge receipt of the BHBA Rules of Procedure and agree to be bound by them. I declare under penalty of law that everything I have stated is true to the best of my knowledge.


DATE                  PETITIONER’S SIGNATURE (COUNSEL MAY NOT SIGN FOR CLIENT)


DATE                  PETITIONER’S SIGNATURE (if more than one)

BHBA FORM F REVISED APRIL 2002