ATTACHMENT FM-1067 ATTORNEY OR PARTY WITHOUT AN ATTORNEY (Name and Address): TELEPHONE NUMBER: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 201 North First Street, San José, CA 95113 191 North First Street San José, California 95113 Family Justice Center PETITIONER: RESPONDENT: CLAIMANT: CASE NUMBER: APPLICATION #: APPLICATION FOR PAYMENT OF ATTORNEY FEES AND COSTS OF CHILDREN'S COUNSEL I, APJ: DEPARTMENT: , declare the following: , 1. I am the Child(ren)'s Counsel in the above-entitled action. I was appointed on by the Honorable matter: 2. I, and/or my staff, have completed of and 3. At my billing rate of $ hours of work on this matter between the date . per hour, I have billed a total in fees and costs of $ per hour. My usual hourly rate is $ during this per hour. to represent the following child(ren) in this . time period. Billing is at a reduced rate of $ 4. This matter, as it pertains to my client(s), is complete. An order has been entered, or I am currently requesting that an order be entered for that reason, terminating my appointment. 5. I am now requesting attorney fees and costs from for the through hours that I and/or my staff have spent on behalf of the minor child(ren) since my last application for an order for fees. since my appointment, or 6. I am now requesting that the court order the replenishment of the retainer. I ask that each party pay the amount of $ to me within fifteen (15) days of the date the Order for Fees is filed. FM-1067 REV 08/01/16 APPLICATION FOR PAYMENT OF ATTORNEY FEES AND COSTS OF CHILDREN'S COUNSEL Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHMENT FM-1067 PETITIONER: RESPONDENT: CASE NUMBER: 7. Each month since my appointment I have sent billing statements to the parties through their attorneys of record, or, if self-represented, to the party directly. I am submitting with this application, copies of those statements as Exhibit "A," not to be filed in the court file. My time was billed at the rate of $ per hour. If applicable, I have billed paralegal time at the rate of $ per hour. I have recorded hours at no charge. 8. I am requesting fees in the amount of and costs in the amount of court allocate the payment of such fees and costs as follows: % to be paid by Mother; % to be paid by Father; % to be paid by the Superior Court for the following reason(s): . I recommend that the 9. I mailed a copy of this Application and Exhibits with a blank Response and blank Income and Expense Declaration to the parties or their attorneys of record on A copy of this Application and Exhibits with a blank Response and blank Income and Expense Declaration was served on the parties or their attorneys of record on . . . 10. 11. 12. I am submitting this Application and Exhibits to the clerk of Department I am submitting this Application and Exhibits to the Superior Court Finance Department. I request Abstracts of Judgment and Earnings Withholdings Orders be issued for the following reasons: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Child(ren)'s Counsel NOTICE TO PARTIES: You must complete the form "Response to Application for Payment of Fees and Costs of Children's Counsel" and follow the procedures set out in that form. Your response must be received within 21 calendar days of the date of this application. See "Payment Procedure for Children's Attorney," enclosed. Failure to submit a response may result in an order directing you to pay up to 100% of the fees and costs requested. *or mailed to: Superior Court of California, County of Santa Clara 191 North First St., San José, CA 95113 FM-1067 REV 08/01/16 APPLICATION FOR PAYMENT OF ATTORNEY FEES AND COSTS OF CHILDREN'S COUNSEL Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com