State of Alabama Unified Judicial System Form CR-64C ATTORNEY’S FEE DECLARATION Rev.8/06 (Juvenile) [For Work Performed Before 6/10/99] Case Number County Code __ __ __ ____ _____ __ Jurisdiction Year Case# Suffix IN THE JUVENILE COURT Attorney Name (Please Type or print) OF ____________________________ COUNTY ________________________________________________________ In the matter of juvenile case number above ________________________________________________________ Social Security Number of FEIN Indicate if: Capital Case ______ (CC) Appeal to the court of: Alabama Court of Criminal Appeals Alabama Court of Civil Appeals Supreme Court of Alabama Other _______ (NC) Type of Case Delinquency Dependency In Need of Supervision Other (Describe) ____________________________________________ The undersigned attorney declares that on (date) __________________________________, the Honorable ___________________________________ ______________________________________________________________________________, Judge, appointed the undersigned to represent the _______ child or ________ parent/guardian, and on (date) _______________________________________ the case was disposed of by ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ (Adjudication of dependency, in need of supervision or delinquency, cert. Denied, etc.) The undersigned attorney further declares that he/she has provided services in the case as attorney or guardian and litem and makes the following claims for such services: (1) In court Appearance Total Hours __________ x $ 40.00 = ___________________ (2) Out of Court Preparation (Trial Level) Total Hours __________ x $ 20.00 = ___________________ (3) Our of Court Preparation (Appellate Level) Total Hours __________ x $ 40.00 = ___________________ (4) Extraordinary Expenses (If approved in advance by court) (5) Overhead Expenses Total Hours __________ x $ ____ = ___________________ TOTAL CLAIM OF ATTORNEY NOTICE TO ATTORNEY: Complete this form. Attach a copy of a complete itemization of (1) in-court appearance; (2) out-of-court preparation; (3) extraordinary expenses reflecting the date of actions and amount of time involved in each activity. Make a copy of same for the court’s record and a copy or your records. 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 _____________________________________ Sworn to and subscribed before me this ____________ Mailing Address of Attorney (please type or print) (including city, state, and zip code) Day of ___________________________, ___________ _________________________________________________________________ _________________________________________________________________ _____________________________________________ _________________________________________________________________ Notary Public Telephone Number _________________ Fax Number _________________ I, the undersigned judge, hereby certify that the foregoing claim has been presented tome, and I have reviewed the same and believe the same to be true and correct. I am further of the opinion that said attorney is not duplicating said charges and expenses in any case (companion or otherwise). Based on the above, I hereby approve the declaration and claim in the amount of $ __________________________________________________ Done this _______________ day of _______________________________, ___________. _________________________________________________________________ Judge’s Signature NOTICE TO ATTORNEY AND JUDGE: Sections 15-12-21 through 15-12-23, code of Alabama 1975, provide that fees and expenses of court appointed attorney’s shall be paid by the State of Alabama. THIS FORM MUST CONTAIN ORIGINAL SIGNATURES OF THE ATTORNEY AND THE JUDGE. THIS FORM WITH ATTACHED ITEMIZATION MUST BE SUBMITTED TO THE TRAIL COURT JUDGE OR PRESIDING JUDGE OR CHIEF JUSTICE OF THE APPELLATE COURT FOR APPROVAL. AFTER APPROVAL, FILE WITH THE CLERK, WHO SHALL SUBMIT THE ORIGINAL DECLARATION TO THE STATE COMPTROLLER FOR AUDIT AND ALLOWANCE. MAIL TO: State Comptroller, Indigent Defense Section, P.O. BOX 302602, Montagomery, Alabama 36130-2602. Original: Comptroller Yellow: Court File Pink: Attorney American LegalNet, Inc. www.FormsWorkflow.com