AUTHORITY TO REIMBURSE COURT APPOINTED COUNSEL (CIVIL) 1. CASE NUMBER2. IN THE CASE OFvs.7. DESCRIPTION AND JUSTIFICATION FOR EACH EXPENSE. Use additional sheets if necessary. 8. ATTORNEY'S STATEMENT9. ESTIMATED AMOUNTAs the attorney for the person represented who is named above,I hereby affirm that the expenses requested are necessary foradequate representation pursuant to Local Rule 83.5.3.1. Ihereby request authorization to incur the expense. (Note: As the reimbursement of expenses isdiscretionary with the court, prior approval is required.10. COURT ORDERFinancial 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. PLAINTIFF'S CERTIFICATION13. 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 SIGNATUREDATESIGNATURE OF PLAINTIFFDATE APPROVED FOR PAYMENT 14.15. TOTAL APPROVED DATESIGNATURE OF PRESIDING JUDICIAL OFFICERJUDGE/MAG. CODE 16. Payment of over $3,000 approved pursuant to Local Rule 83.5.3 17. ACCOUNTINGCLASSIFICATION SIGNATURE OF CHIEF JUDGEDATE7/03 $$ Estimated expenses over $3,000 approved pursuant toLocal Rule 83.5.3 SIGNATURE OF CHIEF JUDGEDATE 3. PERSON REPRESENTED (Full Name)4. NAME OF ATTORNEY5. ATTORNEY'S ADDRESS (include city, state and zip code)6. ATTORNEY'S SOCIAL SECURITY NUMBER OR EMPLOYER I.D.NUMBER American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURTFOR THE DISTRICT OF KANSASINSTRUCTIONS FOR COUNSEL APPOINTED IN CIVIL CASES1.Court appoints an attorney.2.Appointed counsel downloads the form AUTHORITY TO REIMBURSE COURTAPPOINTED COUNSEL (CIVIL) and the Procedures of Court Appointed CounselIn Civil Actions Seeking Special Approval for Reimbursement Pursuant to LocalRule 83.5.3 from the court222s web site at www.ksd.uscourts.gov.3.The attorney completes items 1-9 of the form and submits to the clerk222s office.4.The clerk222s office forwards the form to the presiding judge for approval.5.The presiding judge signs the form in block 10. If the estimated amountexceeds $3,000.00, the form will be forwarded to the Chief Judge forapproval.6.Upon approval, the courtroom deputy for the presiding judge mails the originalform to the attorney for retention until the termination of the case and forwards acopy of the form to the Bar Fund Administrator to maintain.7.When the case is terminated, counsel seeking reimbursement for expenses willcomplete items 11-13 and return the original form to the clerk222s office for finalapproval.8.Upon receipt of completed form, the clerk222s office will forward it to thepresiding judge for approval.9.If the amount approved is over $3000.00, the form will be forwarded to the ChiefJudge for final approval.10.The courtroom deputy for the presiding judge forwards the approved form to theBar Fund Administrator to process for payment. 11.The courtroom deputy for the presiding judge also makes a remark on the docketindicating that the form has been forwarded to the Bar Fund Administrator toprocess for payment.12.Once payment is disbursed, the Bar Fund Administrator shall notify thecourtroom deputy. The courtroom deputy will then edit the remark on the docketwith a notation regarding the amount disbursed and the date of disbursement.(03/05) American LegalNet, Inc. www.FormsWorkFlow.com Office of the ClerkUnited States District CourtDistrict of KansasRevised March 2005 United States District CourtDistrict of KansasProcedures of Court Appointed CounselIn Civil ActionsSeeking Special ApprovalforReimbursementPursuant to Local Rule 83.5.3 American LegalNet, Inc. www.FormsWorkFlow.com The District of Kansas Local Rule83.5.3 addresses procedures to be followedby court-appointed counsel who representindigent parties in civil cases. Counsel mustfollow these procedures if they wish to seekreimbursement for out-of-pocket expenditureswhich counsel are reasonably compelled toincur, which the client is not able to pay, andwhich are not otherwise recoverable in theaction (including settlement).As stated in the Rule, 223To qualify forreimbursement, all expenditures must beapproved in advance by the court.224 The formfor court appointed counsel and instructionscan be found on the public web site atwww.ksd.uscourts.gov .When seeking advance approval forexpenses, counsel should complete Items 1through 9 of the 223Authority to Reimburse CourtAppointed Counsel (CIVIL)224 form and submit itto the clerk222s office. The clerk222s office willforward the form for approval by the presidingjudge and, if the requested amount exceeds$3,000, by the chief judge as well. Counselmay expect to be contacted by the presidingjudge and/or the chief judge if furtherexplanation of the request is necessary. If therequest is approved, counsel will be notifiedthat they are authorized to incur the expenses.The original form will be mailed to the attorneyfor retention until the termination of the case.Once the case is closed, counselseeking reimbursement should complete Items11 through 13 and return it to the clerk222s office.Upon receipt of the completed form, the clerk222soffice will forward the form to the appropriatejudge for approval of payment.Please remember that if you settle thecase and do not recover your expenses orreserve the right to seek costs, the judge willlikely deny reimbursement. Since these fundsare being paid from the Court222s BarRegistration Fund over which the Court has aresponsibility to all members of the Bar thatthese funds are properly spent, the Court mustbe careful about its stewardship of these funds.Accordingly, counsel will be required to makea showing of continuing indigency of theplaintiff at the time reimbursement is sought.While the Court appreciates the pro bonoservices of counsel, approval and authorizationof expenditures will be limited.IT IS REQUIRED THAT COUNSEL SEEKCOURT APPROVAL IN ADVANCE OFINCURRING ANY EXPENSES FOR WHICHREIMBURSEMENT IS SOUGHT. American LegalNet, Inc. www.FormsWorkFlow.com