Approved, SCAO PROBATE JIS CODE: ASE Original - Court 1st copy - Attorney JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE STATE OF MICHIGAN STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT-APPOINTED REPRESENTATIVE CASE NO. ORI Court address Court telephone no. MI- The State of Michigan THE PEOPLE OF v Defendant/Respondent name, address, and telephone no. CTN SID DOB Juvenile Probate In the matter of STATEMENT OF SERVICE 1. I, Name (type or print) , was appointed by the court to serve as the for , and services have been rendered. Specify attorney, lawyer-guardian ad litem, etc. Name (type or print) 2. Compensation from any other source is not being sought. 3. Dates and the nature of services rendered and expenses are as follows: DATE SERVICE/EXPENSE TIME DATE SERVICE/EXPENSE TIME Date Federal identification no. Attorney/Guardian ad litem/Lawyer-Guardian ad litem signature Address City, state, zip Bar no. Telephone no. ORDER FOR PAYMENT I certify that child(ren) and that the service was rendered. IT IS ORDERED District control unit/County was appointed to represent the named defendant/respondent/ disbursing officer shall pay $ to to compensate him/her for all time and expense in connection with this case. Name (type or print) Date Judge Bar no. Check no. MC 221 (6/14) in the amount of $ issued on Date . STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT-APPOINTED REPRESENTATIVE American LegalNet, Inc. www.FormsWorkFlow.com