CJA 21 AUTHORIZATION AND VOUCHER FOR EXPERT AND OTHER SERVICES (Rev. 05/12) 1. CIR./DIST./ DIV. CODE 3. MAG. DKT./DEF. NUMBER 7. IN CASE/MATTER OF (Case Name) 2. PERSON REPRESENTED 4. DIST. DKT./DEF. NUMBER 8. PAYMENT CATEGORY VOUCHER NUMBER 5. APPEALS DKT./DEF. NUMBER 9. TYPE PERSON REPRESENTED 6. OTHER DKT. NUMBER 10. REPRESENTATION TYPE (See Instructions) ' Felony ' Misdemeanor ' Appeal ' Petty Offense ' Other ' Adult Defendant ' Juvenile Defendant ' Other ' Appellant ' Appellee 11. OFFENSE(S) CHARGED (Cite U.S. Code, Title & Section) If more than one offense, list (up to five) major offenses charged, according to severity of offense. REQUEST AND AUTHORIZATION FOR EXPERT SERVICES 12. ATTORNEY'S STATEMENT As the attorney for the person represented, who is named above, I hereby affirm that the services requested are necessary for adequate representation. I hereby request: OR ' Authorization to obtain the service. Estimated Compensation and Expenses: Z ' Approval of services already obtained to be paid for by the United States pursuant to the Criminal Justice Act. (Note: Prior authorization should be obtained for services in excess of $800, excluding expenses) Signature of Attorney Date ' Panel Attorney ' Retained Attorney ' Pro-Se ' Legal Organization ATTORNEY'S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS 13. DESCRIPTION OF AND JUSTIFICATION FOR SERVICES (See Instructions) Telephone Number: 14. TYPE OF SERVICE PROVIDER (See Instructions) 01 02 03 04 05 06 07 08 09 10 11 13 14 15 16 15. COURT ORDER Financial eligibility of the person represented having been established to the Court's satisfaction, the authorization requested in Item 12 is hereby granted. Signature of Presiding Judge or By Order of the Court Date of Order Nunc Pro Tunc Date Repayment or partial repayment ordered from the person represented for this service at time of authorization. ' YES ' NO ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' Investigator Interpreter/Translator Psychologist Psychiatrist Polygraph Documents Examiner Fingerprint Analyst Accountant CALR (Westlaw/Lexis, etc.) Chemist/Toxicologist Ballistics Weapons/Firearms/Explosive Expert Pathologist/Medical Examiner Other Medical Voice/Audio Analyst 17 18 19 20 21 22 23 24 25 26 ' Hair/Fiber Expert ' Computer (Hardware/ ' ' ' ' ' ' Software/Systems) Paralegal Services Legal Analyst/Consultant Jury Consultant Mitigation Specialist Duplication Services Other (Specify) ' Litigation Support Services ' Computer Forensics Expert CLAIM FOR SERVICES AND EXPENSES 16. SERVICES AND EXPENSES (Attach itemization of services with dates) a. Compensation b. Travel Expenses (lodging, parking, meals, mileage, etc.) c. Other Expenses FOR COURT USE ONLY AMOUNT CLAIMED MATH/TECHNICAL ADJUSTED AMOUNT ADDITIONAL REVIEW GRAND TOTALS (CLAIMED AND ADJUSTED): 17. PAYEE'S NAME AND MAILING ADDRESS TIN: Telephone Number: CLAIMANT'S CERTIFICATION FOR PERIOD OF SERVICE FROM CLAIM STATUS TO ' Final Payment ' Interim Payment Number ' Supplemental Payment I hereby certify that the above claim is for services rendered and is correct, and that I have not sought or received payment (compensation or anything of value) from any other source for these services. Signature of Claimant/Payee 18. CERTIFICATION OF ATTORNEY I hereby certify that the services were rendered for this case. Date Signature of Attorney 19. TOTAL COMPENSATION 20. TRAVEL EXPENSES 21. OTHER EXPENSES Date APPROVED FOR PAYMENT -- COURT USE ONLY 22. TOTAL AMOUNT APPROVED/CERTIFIED 23. ' Either the total cost (excluding expenses) of all services combined does not exceed $800, or prior authorization was obtained. ' Prior authorization was not obtained, but in the interest of justice the Court finds that timely procurement of these necessary services could not await prior authorization, even though the cost (excluding expenses) exceeds $800. Signature of Presiding Judge 24. TOTAL COMPENSATION 25. TRAVEL EXPENSES Date 26. OTHER EXPENSES Judge Code 27. TOTAL AMOUNT APPROVED 28. PAYMENT APPROVED IN EXCESS OF THE STATUTORY THRESHOLD UNDER 18 U.S.C. § 3006A(e)(3) Signature of Chief Judge, Court of Appeals (or Delegate) Date Judge Code American LegalNet, Inc. www.FormsWorkFlow.com