AUTHORITY TO REIMBURSE COURT APPOINTED () 1. CASE NUMBER 2. IN 7. . Use additional sheets if necessary. 8.ATTORNEY'S STATEMENT9.ESTIMATED AMOUNT As the attorney for the person represented who is named above,I hereby affirm that the expenses requested are necessary forpursuant to Local Rule 83.5.3. Ihereby request authorization to incur the expense. (Note: As the reimbursement of expenses isdiscretionary with the court, prior approval is required. 10.COURT ORDER Financial eligibility of the person represented having beenestablished to the court's satisfaction, the authorizationrequested in Item 8 is hereby granted not to exceed theestimated amount. DATESIGNATURE OF ATTORNEY TELEPHONE NO.SIGNATURE OF PRESIDING JUDICIAL OFFICERDATE CLAIM FOR EXPENSES 11.ITEMIZATION OF EXPENSES INCURRED (Include dates and description of expenses and basisfor claim. Attach receipts for expenses incurred. Use additional sheets if necessary.)A.TOTAL AMOUNT CLAIMED$ 12. 'S CERTIFICATION 13.CERTIFICATION OF ATTORNEY I herebycertify that these expenses were incurred. I hereby certify under penalty of perjury that I am without thefinancial resources to pay these expenses. ATTORNEY'S SIGNATUREDATE SIGNATURE OF DATE APPROVED FOR PAYMENT 14.15.TOTAL APPROVED DATESIGNATURE OF PRESIDING JUDICIAL OFFICERJUDGE/MAG. CODE 16.Payment of over $0 approved pursuant to Local Rule 83.5.3 17.ACCOUNTINGCLASSIFICATION SIGNATURE OF CHIEF JUDGEDATE $$ Estimated expenses over $ approved pursuant toLocal Rule 83.5.3 SIGNATURE OF CHIEF JUDGEDATE 3. REPRESENTED (Full Name) 4. NAME OF ATTORNEY 5.ATTORNEY'S ADDRESS (include city, state and zip code)6. ATTORNEY'S American LegalNet, Inc. www.FormsWorkFlow.com