Attorney or Party without attorney (Name and Address) Telephone No.: Attorney for: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SHASTA MAILING ADDRESS: 1500 Court Street 1500 Court Street STREET ADDRESS: CITY AND ZIP CODE: Redding, CA 96001 BRANCH NAME: THE PEOPLE OF THE STATE OF CALIFORNIA, PLAINTIFF, vs. _________________________________________, DEFENDANT. CLAIM FOR PAYMENT BY COURT-APPOINTED COUNSEL Case Number: ________________ Claim Filing Date: _____________ Order Due Date: _______________ 1. I,___________________________, hereby state: That I am an attorney duly licensed to practice law in the State of California. 2. That I was appointed to represent the above-referenced defendant on _____________by the Honorable Judge _____________________ during proceedings in Superior Court. 3. The case: (please check one) did proceed to trial did not proceed to trial. 4. Representation ceased on __________________ as a result of: My declaration of conflict if interest The substitution of a private non-court appointed attorney Dismissal of charges Dismissal of charges as a result of a plea bargain in another case Sentencing Filing and perfection of a Notice of Appeal 5. This claim is for: a) Final payment of fees and costs* b) An interim payment of fees costs (*If this claim is requesting final payment and no previous interim claims have been filed, please proceed to Section 8.) _____________________________________________________________________________________ _ Form Approved for Mandatory Use Shasta County Superior Court LF-CRM-100[rev July 1, 2012] CLAIM FOR PAYMENT BY COURTAPPOINTED COUNSEL Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com 6. Please select all that apply: a) I have previously submitted this claim. As a result of my previous submissions of this claim, the court ordered payment: In full Reduced to: $___________ Fees, and $ ___________Costs Increased to $__________ Took no action and the claim is presently pending I have not billed any time on this matter that has been billed previously or will be billed in b) the future to other clients. c) I have not previously submitted this claim. (Please go to Section 8) 7. If you have filed claims for interim payments of fees and costs please complete the following: a) I have filed claims for interim payments of fees and costs on ___ prior occasions. b) The last claim for interim payment that I filed, (Number __) was dated _______ in the amount of $___________fees and $ __________costs, and totaled $________. As a result of that claim, the court ordered payment: In full Reduced to $ _________Fees, and $ _____________Costs Increased to $ Took no action and the claim is presently pending 8. Expenses for reasonable ancillary services or expenses: a) were not incurred (Please go to Section 9) b) were incurred ( Select all that apply): Written authorization to use ancillary service and expenses was obtained prior to said expense being incurred. Was not obtained prior to said services and expenses being incurred, but was obtained immediately after engaging such services. Order(s) authorizing use of ancillary services are attached as Exhibit(s). The amount sought for payment of ancillary services exceeds the amount previously authorized by the court and the reason(s) for such excess services is set forth in the attached declaration. 9. Total service hour(s) announced upon inquiry by the Court were __ hour(s). A difference of ___ hour(s) exists for the reasons set forth by attached declaration. 10. Services and expenses were rendered and incurred as reasonably necessary to the defense of the abovenamed defendant and have not been included in prior claims for payment and are attached. 11. Copies of billing statements and receipts for expenses for which reimbursement is sought are attached. WHEREFORE, the Petitioner prays that the court order the sum of $ _______ to be paid for the defense of the above-named defendant. I declare under penalty of perjury that the foregoing claim for payment of court appointed counsel is true and correct. Executed this ____ day of __________, 20__, at Redding, California. _____________________________________________________________________________________ _ Form Approved for Mandatory Use Shasta County Superior Court LF-CRM-100[rev July 1, 2012] CLAIM FOR PAYMENT BY COURTAPPOINTED COUNSEL Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ________________________ Attorney for Defendant STATEMENT OF SERVICES RENDERED AND EXPENSES INCURRED DATE SERVICE TIME SPENT _______ TOTAL HOURS SPENT: HOURLY RATE: TOTAL FEES: $ 60.00 $ EXPENSES DATE INCURRED DESCRIPTION AMOUNT ____________ TOTAL EXPENSES: $ TOTAL FEES AND EXPENSES: $ _____________________________________________________________________________________ _ Form Approved for Mandatory Use Shasta County Superior Court LF-CRM-100[rev July 1, 2012] CLAIM FOR PAYMENT BY COURTAPPOINTED COUNSEL Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com _____________________________________________________________________________________ _ Form Approved for Mandatory Use Shasta County Superior Court LF-CRM-100[rev July 1, 2012] CLAIM FOR PAYMENT BY COURTAPPOINTED COUNSEL Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com