UNITED STATES DISTRICT COURT DISTRICT OF MASSACHUSETTS PURCHASE ORDER/REQUEST FOR PAYMENT FOR INTERPRETING SERVICES V. CASE NUMBERPLEASE PRINT OR TYPE Name Address City State Zip Code Social Security Number Telephone NumberI hereby certify that I am Certified Non-Certified Prof. CertifiedFROM: TYPE OF PROCEEDINGS: Description: Location: DATE:to interpret in the following Language and executed a contract with the Court on Begin Time:am/ pmam/ pm End Time: HALF DAY FULL DAY AMOUNTDistance from residence to location must be more than 30 miles one way in order to claim any travel expenses.TRAVEL EXPENSES@ PER MILE TOLLS PARKING AMOUNT AMOUNT # OF MILES (Itemize and attach receipts)OTHER EXPENSES: AMOUNT Courtroom Deputy/CJA Attorney verification that information is correct and accurate:(intials) DOCUMENT TRANSLATION: DATE: TOTAL # OF WORDS/PAGES AMOUNT RATE PER WORD OTHER EXPENSES: AMOUNT TOTAL AMOUNT OF INVOICE I hereby certify that I rendered the services described herein, that said services were rendered in accordance with the Contract Court Interpreter Services Terms and Conditions, and that no other federal court unit, Federal Public Defender, Community Defender Organization, or other attorneys or entities obtaining interpreting services under the CJA or the Defender Services appropriation has been or will be billed for the same period of service, cancellation or travel expenses. Date: Signature: Date Approved: Certifying Officer: Title: Certified and Professionally Skilled - Full Day $ / Half Day $ / Overtime $5 per hour or part thereof Language Skilled (Non-Certified) - Full Day $ / Half Day $1 / Overtime $3 per hour or part thereof ** Mileage . Eff. /1/201 (INTERPRETER INVOICE /1/201 - previous editions obsolete) 092000-DXXBBCX-D01MAXJ/M-2523INTERPRETER RATES: Effective American LegalNet, Inc. www.FormsWorkFlow.com