ATTACHMENT A: SERVICES PERFORMED (If the defendant in this matter is represented by an attorney, this form must be reviewed and signed by the attorney of record. Signature of the attorney of record does not obligate the Court and/or County to pay all of the requested fees.) CASE TITLE: CASE NUMBER: (Include detail required by FCSC General Claim Processing Practices, including number of pages read & reviewed.) (If mileage is requested by experts or investigators, include on this form, on a separate line. Place of origin and destination must be included for mileage requests.) DATE OF SERVICE SERVICES RATE HOURS MILES AMOUNT $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 $ 0.00 TOTAL 0.00 0.00 $ 0.00 I am the attorney of record in this matter. I have reviewed this form and represent that the amount requested is reasonable considering the nature and complexity of this case. Signature Date Print Name PGN-91 R04-13 American LegalNet, Inc. www.FormsWorkFlow.com