STATE OF MICHIGAN PROBATE COURT COUNTY OF OAKLAND STATEMENT OF SERVICES AND ORDER FOR PAYMENT GENERAL PROBATE CASE NO. JUDGE For Mental Health cases, use Mental Health Statement of Services form In the matter of Complete separate Statement of Services for each file unless companion cases. Attorney Name Phone # P # Address Vendor ID # City, State, Zip Appointment Date I was appointed to serve as Attorney or GAL for: This is a complete and accurate record of the services I rendered. Name APPOINTMENT TYPE Code Fee per case Hearing date(s) Petition dismissed before hearing PTD $120 Decedent Estate with insufficient funds DEC $215 Temp/Emerg Guard ianship or Cons ervatorship h earing EMT $215 /temporary/emergency hrg. Minor/Adult conservatorship with insufficient funds MIC/ADC $215 Minor/Adult guardianship MIG/LIP $215 Developmentally Disabled Person DDP $215 ( Atty or GAL ) Adjournment (in court/no notice) ADJ $50 ADDITIONAL MATTERS Jury Trial JUR $350 GAL report/no hearing REP $120 Review Hearing/Status Conference REV $215 Extraordinary Fees (Provide an itemized explanation) EXT $60 /hour Total $ Appeals ($500 maximum) APP $60 /hour Total $ Excess Travel (calculated from courthouse): 50 to 74 Miles $25.00 75 to 99 Miles $37.50 100 + Miles $50.00 I declare that the above statements are true to the best of my information, knowledge, and belief. Date Attorney Signature ORDER IT IS ORDERED: The above named attorney has rendered this service and shall be paid (less any applicable Federal or State court ordered and/or statutory lien, levy or garnishment) dollars from the County Treasurer. Date Probate Judge Please Return to: BUSINESS OFFICE OAKLAND COUNTY CIRCUIT COURT 1200 N. TELEGRAPH ROAD, DEPT. 404 PONTIAC, MI 48341 - 0404 Telephone (248) 452 - 2078 Fax (248) 975 - 9877 ORI MI - 630013J PEMH 1092 (10/18) STATEMENT OF SERVICES AND ORDER FOR PAYMENT GENERAL PROBATE American LegalNet, Inc. www.FormsWorkFlow.com