CJA 28H (Rev. 10/12) Other Services Summary Budget Worksheet for Non-capital Representations with the Potential for Extraordinary Cost This summary budget worksheet summarizes anticipated "other" services. The document should be submitted to the court in representations that "appear likely to become or have become extraordinary in terms of potential cost" as set forth in section 230.26.10 of the Guidelines for Administering the CJA and Related Statutes, Volume 7A, Guide to Judiciary Policy. The accompanying detailed budget worksheet may be of assistance to counsel in preparing the summary. The document automatically totals hours and dollar amounts. Date: Case Name: Case Number: Type of Service: Name of Provider: Hourly Rate: Other Service Hours I. Nature and Purpose of Services A. Nature: Purpose: B. Nature: Purpose: C. Nature: Purpose: D. Nature: Purpose: II. Estimated Hours of Services (including travel time) Total Hours: American LegalNet, Inc. www.FormsWorkFlow.com CJA 28H (Rev. 10/12) Other Services Summary/Page 2 Dollars III. Travel Expenses Travel Costs: IV. Other Miscellaneous Costs and Expenses Miscellaneous Costs and Expenses: Approved Case Budget for Other Services: Other Services Time Hourly Rate: Hours: $0.00 0.0 Dollars Fees Approved (hours multiplied by hourly rate): Travel Costs: Other Miscellaneous Costs and Expenses: $0.00 $0.00 $0.00 Grand Total Budget for Other Services: $0.00 American LegalNet, Inc. www.FormsWorkFlow.com