AUTHORITY TO REIMBURSE COURT APPOINTED COUNSEL (CIVIL) 1. CASE NUMBER 2. IN THE CASE OF V. 3. PERSON REPRESENTED (Full Name) 4. NAME OF ATTORNEY 5. ATTORNEY’S ADDRESS (include city, state and zip code) 6. ATTORNEY’S SOCIAL SECURITY NUMBER OR EMPLOYER I.D. NUMBER 7. DESCRIPTION AND JUSTIFICATION FOR EACH EXPENSE. Use additional sheets if necessary. 8. ATTORNEY’S STATEMENT As the attorney for the person represented who is named above, I hereby affirm that the expenses requested are necessary for adequate representation pursuant to the court’s Policy Regarding Reimbursement of Costs in Pro Bono Civil Cases. I hereby request authorization to incur the expense. 9. ESTIMATED AMOUNT $ (Note: As the reimbursement of expenses is discretionary with the court, prior approval is required.) 10. COURT ORDER * SIGNATURE OF ATTORNEY DATE Financial eligibility of the person represented having been established to the court’s satisfaction, the authorization requested in item 8 is hereby granted not to exceed the estimated amount. * SIGNATURE OF PRESIDING JUDICIAL OFFICER TELEPHONE NO. DATE Estimated expenses over $5,000 approved pursuant to the court’s Policy Regarding Reimbursement of Costs in Pro Bono Civil Cases * SIGNATURE OF CHAIR, BENCH BAR FUND COMMITTEE DATE CLAIM FOR EXPENSES 11. ITEMIZATION OF EXPENSES INCURRED (Include dates and description of expenses and basis for claim. Attach receipts for expenses incurred. Use additional sheets if necessary.) A. TOTAL AMOUNT CLAIMED $ 12. CERTIFICATION OF ATTORNEY I hereby certify that these expenses were incurred, that I have pursued all other avenues of cost reimbursement, and that my client is unable to pay these costs. * ATTORNEY’S SIGNATURE DATE APPROVED FOR PAYMENT 13. * SIGNATURE OF PRESIDING JUDICIAL OFFICER 14. TOTAL APPROVED $ DATE JUDGE/MAG. CODE 15. Payment of over $5,000 approved pursuant to Policy Regarding Reimbursement of Costs in Pro Bono Civil Cases * SIGNATURE OF CHAIR, BENCH BAR FUND COMMITTEE 16. ACCOUNTING CLASSIFICATION DATE Revised: 8/29/2006 American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDA INSTRUCTIONS FOR COUNSEL APPOINTED IN Pro Bono CIVIL CASES 1. Court appoints an attorney. 2. Appointed counsel downloads the form, AUTHORITY TO REIMBURSE COURT APPOINTED COUNSEL (CIVIL) and the Bench Bar Fund’s Policy Regarding Reimbursement of Costs in Pro bono Civil Cases from the court’s web site at www.flmd.uscourts.gov. 3. The attorney completes items 1-9 of the form and submits to the clerk’s office. 4. The clerk’s office forwards the form to the presiding judge for approval. 5. The presiding judge signs the form in block 10. 6. Upon approval, the courtroom deputy for the presiding judge mails the original form to the attorney for retention until the termination of the case and forwards a copy of the form to the Bench Bar Fund Administrator to maintain. 7. When the case is terminated, counsel seeking reimbursement for expenses will complete items 11-12 and return the original form to the clerk’s office for final approval. (Note: counsel may incur up to $500.00 in expenses without prior approval, subject to later request to the Court for reimbursement.) 8. Upon receipt of the completed form, the clerk’s office will forward the form to the presiding judge for approval. 9. If the amount approved by the presiding judge is over $5,000.00, the form will be forwarded to the Chair of the Bench Bar Fund Committee for Committee final approval. 10. The courtroom deputy for the presiding judge will forward the approved form to the Bar Fund Administrator to process for payment. 11. The courtroom deputy for the presiding judge will make a “remark” on the docket indicating that the form has been forwarded to the Bar Fund Administrator to process for payment. Revised: 8/29/2006 American LegalNet, Inc. www.FormsWorkflow.com