LEGAL PAYMENT INTAKE
Payment year:
Payer legal entity:
Payment date/reference/channel:
Gross amount:
Actual payee names:
Disbursing party and role:

PURPOSE
Attorney services / settlement proceeds / mixed / other:
Fee invoice or settlement document reference:
Attorney providing services to whom:
Joint payee details:

COMPONENT REVIEW
Component | gross amount | recipient | proposed form/field | source/reviewer
Attorney fee:
Attorney gross proceeds:
Claimant damages:
Wages:
Interest:
Other:

RECIPIENT DOCUMENTATION
Attorney tax name and restricted TIN source:
Claimant tax-document source:
Unresolved identity or allocation question:
Assigned decision owner/date:

[ ] Corporate status not used as a blanket legal-payment exemption.
[ ] Gross proceeds not reduced to estimated attorney fee.
[ ] Claimant reporting considered separately.
[ ] Payment channel confirmed.
[ ] Form totals reviewed by purpose; duplicate cash assumption avoided.
Approved reporting instructions and date: