State of Alabama Unified Judicial System ATTORNEY’S FEE DECLARATION Form C-62D (Adult) [For Appointments made on or after 6/14/2011] Rev.6/2011 Mark Appropriate Court: Circuit Court of ________________ County District Court of________________ County Alabama Court of Criminal Appeals Alabama Court of Civil Appeals Supreme Court of Alabama Indicate if Original Charge is: Capital Case (or charge carrying sentence of life without parole) Limits Case Number __ ____ _____ __ Jurisdiction Year Case# Suffix Attorney Name (Please type or print) (NO Limit) CC Class A Felony Class B Felony Class C Felony Other Appeal Petition for Writ of Certiorari Post-Conviction/Habeas Corpus County Code __ __ ($4,000) FA ($3,000) FB ($2,000) FC ($1,500) OT ($2,500) AP ($2,500) WC ($1,500) PC ____________________________________________ ____________________________________________ Social Security Number or FEIN ____________________________________________ v. __________________________________________________ Defendant CHARGE: _________________________________________________________________________________________________________ STYLE OF CASE: Companion case numbers and charges or convictions: ______________________________________________________________________ __________________________________________________________________________________________________________________ The undersigned attorney declares that on (date) _____________________________, the Honorable ___________________________________ _________________________, Judge, appointed the undersigned to represent the above-named defendant or appellant, and on (date) ___________________ the case was heard by the Honorable _____________________________________________________________, Judge. The case was disposed of by _________________________________________________________________________________________________ (Please of guilty, conviction, acquittal, affirmance, reversal, cert. denied) (1) (2) (3) (4) (5) In court Appearance (Trial Level or Post-Conviction Proceeding) Out-of-Court Preparation (Trial Level or Post-Conviction Proceeding) Preparation (Appellate Level) Expert Expenses (If approved in advance by court) Reimbursable Non-overhead Expenses (Attach receipts) Total Hours __________ x $ 70.00 per hour = ___________________ Total Hours __________ x $ 70.00 per hour = ___________________ Total Hours __________ x $ 70.00 per hour = ___________________ ___________________ ___________________ TOTAL CLAIM OF ATTORNEY ______________________ NOTICE TO ATTORNEY: Complete this form. Attach a copy of a complete itemization of (1) in-court appearances; (2) out-of-court preparation; (3) preparation for appeals; (4) expert expenses; and/or (5) reimbursable non-overhead expenses reflecting the date of actions and amount of time involved in each activity. Attach original invoice or receipt for all expenses and corresponding court orders. Make a copy of same for the court’s record and a copy or your records. This form and attachments must be received by the Office of Indigent Defense Services no later than 90 days from final disposition of the case. The undersigned attorney further declares that the above claim is true and correct and represents the services actually rendered by him/her as an attorney and the amount is due and payable. I further declare that the above claim is not a duplication of charges and expense4s in any case (companion or otherwise) _________________________________________________________________ Signature of Attorney Attorney Code _____________________________________ Mailing Address of Attorney (please type or print) (including city, state, and zip code) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ E-mail Address:_____________________________________ Telephone Number ____________________ Fax Number ______________________ I, the undersigned judge, hereby certify that the attorney presenting this claim provided representation in this matter and that said matter has been concluded. I am further of the opinion that the claim is reasonable based on the defense provided. _________________________________________________________________ Judge’s Signature ____________________________________ date NOTICE TO ATTORNEY AND JUDGE: Sections 15-12-21 through 15-12-23, Ala. Code 1975, provide for the payment of attorney fees and extraordinary expenses incurred by counsel appointed to represent indigent defendants at the trial level, on appeal (including petition for writ of certiorari to the Alabama Supreme Court), and in post-conviction proceedings. THIS FORM MUST CONTAIN ORIGINAL SIGNATURES OF THE ATTORNEY AND THE JUDGE. THIS FORM WITH ATTACHED ITEMIZATION MUST BE SUBMITTED TO THE TRIAL COURT JUDGE OR PRESIDING JUDGE OR CHIEF JUSTICE OF THE APPELLATE COURT FOR CERTIFICATION, FILED WITH THE CLERK, AND THEN SUBMITTED TO THE OFFICE OF INDIGENT DEFENSE SERVICES. Filed in the Clerk’s Office at _______________________________, Alabama, on __________________________. date MAIL TO: Office of Indigent Defense Services, P.O. BOX 302602, Montgomery, Alabama 36130-2602. American LegalNet, Inc. www.FormsWorkFlow.com