IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MARYLAND * Plaintiff, * v. * Defendant. * REQUEST BY COURT-APPOINTED COUNSEL FOR REIMBURSEMENT OF EXPENSES Name of person represented: Date of appointment: Date of judgment or appointment ended: Case No. Have you previously applied for reimbursement in this case? No Yes Amount Received: $ If you answered yes, attach copies of all prior applications. I hereby request reimbursement for the following costs (do NOT include any expenses previously reimbursed): Deposition expenses (attach invoices or a statement with the deponent's name, date of deposition, number of pages, and per page rate) $ Expert, investigative, or other services (attach receipts; and if approved in advance, a copy of the order approving; if not approved in advance, explain why) Travel expenses, including tolls, parking, and mileage Witness fees/Service fees (attach invoices, receipts or copies of checks) Interpreter services (attach invoices or receipts) $______________ $ $ $ Copies, photographs, long distance calls, etc. (actual out-of-pocket expenses only, not normal office overhead) $ Other expenses (attach receipts and a statement describing expenses) $ TOTAL $ Expenses are limited to a total of $10,000 per case unless otherwise requested by counsel with advance approval by the presiding judge and the Court's Attorney Admissions Fund Committee. Refer to attached instructions for additional information. ReqReimburseExpenses (07/2015) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION I declare under penalty of perjury that the foregoing costs are correct and necessarily incurred in this action and I have not been compensated or reimbursed for these costs from or on behalf of the client. None of the costs listed represent fees or costs taxed against myself or the client. Date Signature Printed name and bar number Address Email address Telephone number Fax number ORDER Expenses in the amount of $ are approved for reimbursement. Date United States District/Magistrate Judge ReqReimburseExpenses (07/2015) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Completing Request by Court-Appointed Counsel for Reimbursement of Expenses NOTE: Regulations Governing the Reimbursement of Expenses in Pro Bono Cases are contained in Appendix C to the Local Rules of the United States District Court for the District of Maryland. This form is only for use in cases where counsel has been court appointed. There is a total expense limit of $10,000.00 per case. Upon request forwarded by the presiding judge, the Attorney Admissions Committee may increase this limit. Counsel is advised to seek approval for expenses in excess of $10,000 before they are actually incurred. A request must be filed no later than thirty days from the entry of judgment or the date counsel's appearance is terminated, whichever is earlier. A request for interim expenses may be made while a case is pending. Do not seek reimbursement for expenses awarded as costs or attorneys' fees. Do not seek reimbursement for costs or expenses awarded against you or your client. Be sure to fill in your client's name, the date of your appointment, and, if applicable, the date of judgment or date your representation ceased. Whenever available attach receipts or invoices for expenses. If other documentation is not available, attach a statement detailing the expense. If the reason an expense was incurred is not readily apparent, attach a statement explaining why it was necessary. Mileage is reimbursable at the rate allowed for government travel at the time the expense was incurred. The current mileage rate is in the Schedule of Fees posted on the Court's website: www.mdd.uscourts.gov or on the GSA website: www.gsa.gov. When you request reimbursement for mileage include the number of miles traveled each way and the rate at which you calculated the amount of reimbursement. Do NOT include any expenses which were previously reimbursed. If interim expenses were approved, fill in the amount approved and attach copies of all interim requests for reimbursement. Upon completion of the form, please file the request electronically in CM/ECF using the Request by Court-Appointed Counsel for Reimbursement of Expenses Event under Other Filings/Other Documents. � � � � � � � � � � � � ReqReimburseExpenses (07/2015) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com