SUPPLEMENTAL FORM

Participating Attorney: Peter Robert Stone

Atty Code

Client Name:

Address

State

City

Zip

Email Address

Date of first visit to the attorney ×

Date service commenced ×

Specific services performed:

I requested the above services, have received all of the above services, and am satisfied with the work and services provided by the attorney. I authorize the release to Legal Plans of any additional information needed to verify services or to make the appropriate payment for my case.

A representative of METLIFE Legal Plans may call me for any additional verification:

Yes

No

Date ×

Specific services performed:

Client Signature:

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