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The original, completed Statement of Costs and Disbursements form. Make at least two copies of the completed Statement of Costs and Disbursements.6) Complete if you filed an Order to Produce Statement of Assets and to Appear for Examination. Show carrying value of assets sold less total sales proceeds. B. Provide copy of broker's statement or signed settlement sheet as verification. VIII. Attorney will incur various costs and expenses in performing legal services under this Agreement. Attorney will incur various costs and expenses in performing legal services under this Agreement. Summary of cash receipts and disbursements statement. 14. Provide a complete proposed Order Determining Attorney Fees. Don't send tax questions, tax returns, or payments to the above address.