SUPERIOR COURT OF CALIFORNIA, COUNTY OF AMADOR 500 ARGONAUT LANE, JACKSON, CA 95642 Name, Address and Telephone No. of Attorney CLERK'S USE ONLY Case No. Case Title: Invoice Date: COURT APPOINTED ATTORNEY CLAIM FORM AND ORDER/REIMBURSEMENT ORDER CLAIM AND REQUEST FOR APPROVAL OF: ATTORNEY FEES INTERIM FINAL REIMBURSEMENT TO AMADOR COUNTY ATTORNEY'S EXTRAORDINARY FEES To the Judge of the Superior Court: On_________________ I was appointed to represent: _______________________________ pursuant to the provisions of: Civil Contempt Family Code 3150 Penal Code ________________ Probate Code W&I Code 317 (Juvenile Dependency) W&I Code 634 (Juvenile Wardship) Other: ____________ _______________________ Billing Period:_____________________ through _____________________TOTAL CLAIM: $______________________ . I declare under penalty of perjury that the itemized statement and claim for services attached hereto is true and correct and accurately reflects the time spent by me in this action. Date:___________________________ Signature: ___________________________________________ ORDER This claim for approval of attorney fees may be used by the Court to make a determination of the amount for which a Defendant is responsible for reimbursing the County for provision of legal services pursuant to Court appointed counsel. The Court having read and reviewed the claim submitted herein orders the following: Defendant does not have the ability to pay has the ability to pay at this time Partial Amount Granted Other:______________ ________________________________________ Amount Approved: $____________________ Date: ____________________________ ______________________________________________________ Judge of the Superior Court The Order Sealing the Request for Approval of Fees was made by the Court on: ________________________. As part of that Order, the invoice and the associated itemized billing are sealed. In order for the invoices to be paid, they must be sent to County officials. The court is hereby authorized to submit approved claim forms, without any itemized statements attached, to the County for payment. The Court sends the claim forms to GSA who in turn sends the forms to the auditor for payment. These County entities are hereby ordered to shred or maintain the claim forms confidentially and not release said claim forms to any other entity, unless authorized to do so by further order of this Court. The itemized statements are to be retained by the Court under seal. The Court's fiscal department may maintain the documents in a locked file cabinet, in a separate file folder indicating they are "sealed." The fiscal department shall not release the records or provide access to anyone, other than as provided by in this order, unless otherwise authorized by further Court Order. American LegalNet, Inc. www.FormsWorkFlow.com COURT APPOINTED ATTORNEY CLAIM FORM AND ORDER & ITEMIZED STATEMENT-(Rev. 022713)-FIN-020 ITEMIZED STATEMENT CASE NO.: SERVICE DATE TYPE OF SERVICE # OF HOURS RATE COST TOTAL # OF HOURS ________ X $_________/HOUR = $ ______________________________________ Date ________________________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com COURT APPOINTED ATTORNEY CLAIM FORM AND ORDER & ITEMIZED STATEMENT-(Rev. 022713)-FIN-020