NAME AND ADDRESS OF VENDOR: PHONE: For Court Use Only: SUPERIOR COURT OF CALIFORNIA, COUNTY OF FRESNO 1100 Van Ness Avenue Fresno, CA 93724-0002 CASE NAME: APPLICATION AND ORDER FOR PAYMENT OF COURT APPOINTED VENDOR (Not to be used for court appointed special circumstance attorney claims) CASE NUMBER: NOTE TO ALL VENDORS: COPY OF COURT ORDER APPOINTING VENDOR MUST ACCOMPANY THIS FORM. STANDARD RATE PSYCHOLOGICAL/ PSYCHIATRIC EVALUATION CLAIM: COURT APPOINTED SERVICES (EXPERT, INVESTIGATOR, ETC.) CLAIM: (Provide Attachment A for itemization of services and mileage, and Attachment B with original receipts for expenses.) a. Date appointed: by Judge a. hours at $ per hour $ 0.00 b. Evaluation date: b. Mileage ( miles at $ per mile) $ 0.00 0.00 c. Type of evaluation: c. Expenses $ 0.00 TOTAL $ 0.00 d. Fee: NOTE: If you have written preapproval for more than Signature of attorney of record required on Attachment A for expert or the standard rate, fill out the expert services portion of investigator billing prior to submission. this form. COURT APPOINTED ATTORNEY DECLARATION AND CLAIM: I am an attorney at law duly admitted to practice in the State of California. I have not received compensation for this claim except as noted below. I hereby make application for payment of fees as follows: (See footnote * below before completing.) A. Appointed on (date) to represent (name) (Client’s relationship to case: ) B. This is the only billing for this case and legal services have been terminated and required less than 3 hours - flat fee $240 $ Expenses: $ C. Interim billing for services from to (If interim billing, date of prior billing: ) D. Legal services terminated on or about (date): E. Attorney’s fees: $ Expenses: $ (other than $240 flat fee) Total amount claimed for A through E (Provide Attachment A for itemization of TOTAL $ 0.00 services and Attachment B with original receipts for expenses): I declare under penalty of perjury that the foregoing is true and correct and that this declaration is executed on (Date): at (Place) , California. (Type or print name) FOR COURT USE ONLY: , (Signature of applicant) ORDER The foregoing application has been considered and the court finds the following fees to be reasonable: a. Fees: $ b. Expenses $ c. Mileage $ TOTAL: $ It is ordered that the total shown above in item 2c be paid by Fresno County Superior Court. Dated: Judge of the Superior Court *Declarations under penalty of perjury signed in California may be used in place of affidavits (CCP 2015.5). Affidavits required when signed outside California. APPLICATION AND ORDER FOR PAYMENT OF COURT APPOINTED VENDOR FEES AND EXPENSES PGN-90 E05-11 American LegalNet, Inc. www.FormsWorkFlow.com