COURT APPOINTMENT FORENSIC EVALUATION EXTRAORDINARY SERVICES REQUEST FOR ADDITIONAL FUNDS PRIOR TO THE PERFORMANCE OF SERVICES Doctor's Name: Defendant/Minor Full Name: Case Number: Type of Proceeding : (Must Select One) Adult PC1368/1369 Adult EC 1017 Juvenile EC 1017 Adult PC1026/1027 Adult PC 288.1 Juvenile WIC 702.3(d) Adult W&I 6605 Juvenile Competency Report Other: FILED DATED:________________ David H. Yamasaki Chief Executive Officer/Clerk Superior Court of California County of Santa Clara By:____________________ Deputy Clerk Justification for request: Please be sure to explain how the circumstances of this evaluation are unusual. If you performed extraordinary services prior to obtaining approval, Provide a detailed explanation as to why prior approval could not be obtained. Date of Interview: X Pages Reviewed: $ Hourly Rate ($85 PhD/$95 MD) Number of hours worked: $ Additional Amount Requested Requested Amount of Additional Payment in addition to Standard Fee Schedule amount Additional Hours = I hereby declare under penalty of perjury that to the best of my knowledge the foregoing information is true and accurate in every respect. Date Doctor's Signature Mailing Address: Phone #: NOTE: Copy of this form (CR-6080) must be attached with the compensation claim form (CR-6079) Order of Court Approved Denied Other: Dated: CR-6080 REV 10/1/12 Judicial Officer of the Superior Court Court Appointment Forensic Evaluation Extraordinary Services Request for Additional Funds Prior to the Performance of Services American LegalNet, Inc. www.FormsWorkFlow.com