I further state that, although I have the right to present this matter to a Court in this State, I wish to waive this right and submit my
case to the New Jersey Supreme Court’s District Fee Arbitration Process. I realize that I have 30 days only from the date this
Request Form is docketed within which I may withdraw, in writing, from the arbitration process. Once the request is withdrawn, I
cannot again file for fee arbitration. I understand that if the total fee charged is less than $3,000, a single attorney arbitrator may
hear the case; otherwise, three arbitrators would decide the case, unless I give my further written consent at the time of the hearing
to proceed with two arbitrators, in accord with the procedures set by Court Rule. I agree that the determination of a Fee
Committee is final and legally binding upon both the attorney and myself, and that the determination is subject to appeal only in
very limited instances of actual fraud, substantial procedural irregularities, failure of an arbitrator to properly be disqualified, or
where the arbitrators make an obvious mistake of law. I am further aware that if the attorney has sued me but I have filed a timely
Request Form, the Court Rules provide that the lawsuit will be stayed, and “the amount of the fee or refund as so determined [by
the Fee Committee] may be entered as a judgment in the action unless the full balance due is paid within 30 days of receipt of the
arbitration determination.” R. 1:20A-3(e). I also understand that, if no suit is pending, the determination of the Fee Committee
may, by summary action, be docketed as a judgment against me, under the same Court Rule. I also understand that fee
proceedings are confidential, and I agree to maintain the confidentiality required by R. 1:20A-5.
I hereby certify that all of the foregoing statements made by me are true, and that all documents attached are true copies of the
originals. I am aware that if any part of this Request Form is willfully false, I am subject to punishment.