AUTHORITY TO REIMBURSE COURT APPOINTED COUNSEL (CIVIL) 1. CASE NUMBER 2. IN THE CASE OF vs. 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 9. ESTIMATED AMOUNT 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 Local Rule 83.5.3.1. I hereby request authorization to incur the expense. $ 10. COURT ORDER 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. (Note: As the reimbursement of expenses is discretionary with the court, prior approval is required. SELECT ONE: Initial Request Supplemental Request SIGNATURE OF PRESIDING JUDICIAL OFFICER SIGNATURE OF ATTORNEY DATE Estimated expenses over $3,000 approved pursuant to Local Rule 83.5.3 DATE TELEPHONE NO. DATE SIGNATURE OF CHIEF JUDGE 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. PLAINTIFF'S CERTIFICATION I hereby certify under penalty of perjury that I am without the financial resources to pay these expenses. SIGNATURE OF PLAINTIFF DATE 13. CERTIFICATION OF ATTORNEY I hereby certify that these expenses were incurred. ATTORNEY'S SIGNATURE DATE APPROVED FOR PAYMENT 14. SIGNATURE OF PRESIDING JUDICIAL OFFICER 15. TOTAL APPROVED DATE JUDGE/MAG. CODE 16. Payment of over $3,000 approved pursuant to Local Rule 83.5.3 SIGNATURE OF CHIEF JUDGE $ 17. ACCOUNTING CLASSIFICATION DATE 7/03 American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT FOR THE DISTRICT OF KANSAS INSTRUCTIONS FOR COUNSEL APPOINTED IN CIVIL CASES 1. Court appoints an attorney. 2. Appointed counsel downloads the form AUTHORITY TO REIMBURSE COURT APPOINTED COUNSEL (CIVIL) and the Procedures of Court Appointed Counsel In Civil Actions Seeking Special Approval for Reimbursement Pursuant to Local Rule 83.5.3 from the court’s web site at www.ksd.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. If the estimated amount exceeds $3,000.00, the form will be forwarded to the Chief Judge for approval. 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 Bar Fund Administrator to maintain. 7. When the case is terminated, counsel seeking reimbursement for expenses will complete items 11-13 and return the original form to the clerk’s office for final approval. 8. Upon receipt of completed form, the clerk’s office will forward it to the presiding judge for approval. 9. If the amount approved is over $3000.00, the form will be forwarded to the Chief Judge for final approval. 10. The courtroom deputy for the presiding judge forwards the approved form to the Bar Fund Administrator to process for payment. 11. The courtroom deputy for the presiding judge also makes a remark on the docket indicating that the form has been forwarded to the Bar Fund Administrator to process for payment. 12. Once payment is disbursed, the Bar Fund Administrator shall notify the courtroom deputy. The courtroom deputy will then edit the remark on the docket with a notation regarding the amount disbursed and the date of disbursement. (11/06) American LegalNet, Inc. www.FormsWorkflow.com United States District Court District of Kansas Office of the Clerk United States District Court District of Kansas Revised March 2005 Procedures of Court Appointed Counsel In Civil Actions Seeking Special Approval for Reimbursement Pursuant to Local Rule 83.5.3 American LegalNet, Inc. www.FormsWorkflow.com The District of Kansas Local Rule 83.5.3 addresses procedures to be followed by court-appointed counsel who represent indigent parties in civil cases. Counsel must follow these procedures if they wish to seek reimbursement for out-of-pocket expenditures which counsel are reasonably compelled to incur, which the client is not able to pay, and which are not otherwise recoverable in the action (including settlement). As stated in the Rule, “To qualify for reimbursement, all expenditures must be approved in advance by the court.” The form for court appointed counsel and instructions can be found on the public web site at www.ksd.uscourts.gov. When seeking advance approval for expenses, counsel should complete Items 1 through 9 of the “Authority to Reimburse Court Appointed Counsel (CIVIL)” form and submit it to the clerk’s office. The clerk’s office will forward the form for approval by the presiding judge and, if the requested amount exceeds $3,000, by the chief judge as well. Counsel may expect to be contacted by the presiding judge and/or the chief judge if further explanation of the request is necessary. If the request is approved, counsel will be notified that they are authorized to incur the expenses. The original form will be mailed to the attorney for retention until the termination of the case. Upon receipt of the completed form, the clerk’s office will forward the form to the appropriate judge for approval of payment. Please remember that if you settle the case and do not recover your expenses or reserve the right to seek costs, the judge will likely deny reimbursement. Since these funds are being paid from the Court’s Bar Registration Fund over which the Court has a responsibility to all members of the Bar that these funds are properly spent, the Court must be careful about its stewardship of these funds. Accordingly, counsel will be required to make a showing of continuing indigency of the plaintiff at the time reimbursement is sought. While the Court appreciates the pro bono services of counsel, approval and authorization of expenditures will be limited. IT IS REQUIRED THAT COUNSEL SEEK COURT APPROVAL IN ADVANCE OF INCURRING ANY EXPENSES FOR WHICH REIMBURSEMENT IS SOUGHT. Once the case is closed, counsel seeking reimbursement should complete Items 11 through 13 and return it to the clerk’s office. American LegalNet, Inc. www.FormsWorkflow.com