U.S. District Court for the Southern District of Indiana Court Interpreter Services INVOICE Social Security No./Taxpayer ID No. _____________________________ Contract/BPA No. _________________________________ (The Contract No. is contained in Box 3 of the “Requisition for Supplies or Service” form – NOT APPLICABLE TO CJA INTERPRETERS.) Name of Interpreter: ______________________________________ Mailing Address: ______________________________________ Services Provided for U.S. District Court: ______________________________________ Language Provided: Spanish Other (specify)_________________________ ______________________________________ Telephone No(s): In Court CJA ______________________________________ Description of Services: Date Start Time End Time Cause No. & Defendant’s Name *Parking Expenses Claimed Amount Claimed *Mileage Claimed Total (No. of Miles ____ x $.51/mi. =_________) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ NOTE: Mileage, parking, and similar expenses are not reimbursed when the contract court interpreter’s $ residence is less than thirty (30) miles from the court location. SUBTOTAL: ADDITIONAL TRAVEL EXPENSES: (Insert amount in the adjacent column from the Additional Travel Expense Form. NOTE: The $ Additional Travel Expense Form MUST be attached, along with any hotel receipt and/or other associated expenses greater than $50. TOTAL AMOUNT CLAIMED: Page 1 of 3 $ American LegalNet, Inc. www.FormsWorkFlow.com I hereby certify that I rendered the services described herein, that said services were rendered in accordance with the Contract Court Interpreter Services Terms and Conditions, and that no other federal court unit, U. S. Probation Office, Federal Public Defender, Community Defender Organization, or other attorneys or entities obtaining interpreting services under the CJA or the Defender Services appropriation has been or will be billed for the same period of service or travel expense. I further certify that any claim for reimbursement of travel expenses is true and correct to the best of my knowledge and belief. Date ____________________________ ______________________________________ Interpreter’s Signature NOTE: Falsification of an item in an expense account causes a forfeiture of claim (28 U.S.C. 2514) and may result in a fine of not more than $10,000 or imprisonment for not more than 5 years or both (18 U.S.C. 287; i.d. 1001). Please ensure the following documents are attached prior to submission of this invoice: • Written Request for Services (Not Applicable to CJA Interpreters) • Itemized Travel Dates/Expenses (if any) • Travel Receipts (any hotel receipt and other authorized expense greater than $50) For Court Use Only Federal Certification Professionally Qualified Page 2 of 3 Language Skilled American LegalNet, Inc. www.FormsWorkFlow.com ADDITIONAL TRAVEL EXPENSES FORM INTERPRETER’S NAME: DATE: TRAVEL RELATED CLAIMS MUST CONTAIN THE FOLLOWING INFORMATION: Date Departure Time from Residence Arrival Time at Court Destination Departure Time from Court Location Arrival Time at Residence at the End of Travel Instructions To The Interpreter: (a) – (c) Itemize the total cost of each meal (including tax and tips) from your actual receipts. (d) Itemize daily lodging expense. (e) Itemize other expenses such as hotel taxes. (f) Calculate total across for each day. DATE Example: 10/1/10 Meals (Actual Expenses) Breakfast Lunch Dinner (a) (b) (c) 5.50 8.75 18.25 ITEMIZED TRAVEL EXPENSES Lodging Other (d) (e) 91.00 15.47 TOTAL: (Please transfer the “Total” amount in Column “f” to the “Additional Travel Expenses” box on the Court Interpreter Services “Invoice.”) Page 3 of 3 TOTAL Description (for “Other” column (e) items, i.e. parking, baggage handling and other items) Hotel Taxes (f) $138.97 $ American LegalNet, Inc. www.FormsWorkFlow.com