PC-024, Rev 01/19 Page 1 of 2 GUARDIAN AD LITEM (GAL) VOUCHER IN RE: DISTRICT COURT: JUDICIAL OFFICER: DOCKET NUMBER: TYPE OF CASE: 000 Child Protection. Stage completed: 000 Summary Preliminary Hearing 000 Jeopardy Hearing 000 Judicial Review and/or Permanency Planning Hearing 000Termination of Parental Rights Hearing 000 Contested (up to 21 hours allowed) or 000 Uncontested (up to 15 hours allowed) Date Stage Completed: 000 Cease Reunification Hearing (if not held with another event) 000 Contested Permanency Guardianship Hearing (22 M.R.S. 4038-C) (if not held with another event) 000 Contested Child Placement Hearing (22 M.R.S. 4005-E (2)) (if not held with another event) 000 Law Court Appeal 000 Family Matter 320 Guardianship (up to 15 hours allowed per Me. Admin Order JB-05-5) 000 Family Matter 320 Adoption 000 Attached is a copy of the Court325s Order Appointing Guardian ad Litem (vouchers will be denied if Order for Appointment of Guardian ad Litem is not attached). 000 Juvenile Matter 000 Attached is a copy of the Court325s Order Appointing Guardian ad Litem (vouchers will be denied if Order for Appointment of Guardian ad Litem is not attached). TOTAL HOURS (In .1 increments. Attach itemization of time) : 000 VOUCHER EXCEEDS NUMBER OF ALLOWABLE HOURS. The voucher exceeds the maximum number of hours allowed by Me. Admin. Order JB-05-5 (A. 7-16) (effective October 1, 2017). 000 A motion to exceed the maximum allowed hours was filed on . 000 Attached is a copy of the court order pre-approving the additional time (voucher will be denied if court order pre-approving additional time is not attached). TOTAL MILEAGE (Allowable mileage x state rate) : Date Origin Address Destination Address Total Miles Purpose of Travel TOTAL OTHER EXPENSES (Attach itemization/receipts): $ I certify that payment has not been received, and that no payment or promise of payment has been requested or accepted by me in connection with this case, except as ordered by the court. The attached statement of time spent in preparation, in court, and on expenses is true and correct. I further certify that my billing is in accord with Administrative Order JB-05-5, and in particular that I have not billed for travel time or expenses to/from my declared home court(s) and that I have not double-billed for my time. American LegalNet, Inc. www.FormsWorkFlow.com PC-024, Rev 01/19 Page 2 of 2 This voucher was filed in one of my designated Home Courts? Yes No Signature of GAL Name of GAL (print) Telephone Number Email Address Date submitted Check Payable To Re-submission Yes No Address Vendor Code # ALL INFORMATION ABOVE THIS LINE MUST BE COMPLETED OR VOUCHER WILL BE RETURNED. Hourly Fee $ Mileage $ Other Expenses $ TOTAL DUE $ FOR COURT USE ONLY Clerk Verification: Name (print) (Signature) Court Date Stamp Total Hours/Mileage/Other Expenses AOC Approved for Payment APPROVED BY: (Signature) Judge Date: Clerk Fund Agency Unit Approp. Object 010 40A 012 4040 (Date) JUDICIAL OFFICER NOTES: TRANS AGENCY DOCUMENT I.D # TYPE CODE GAX 40 A American LegalNet, Inc. www.FormsWorkFlow.com