STATEMENT OF SERVICES AND ORDER FOR PAYMENT OF COURT APPOINTED ATTORNEY AND GUARDIAN AD LITEM STATE OF MICHIGAN SIXTH JUDICIAL CIRCUIT OAKLAND COUNTY PROBATE CASE NO. In the matter of Attorney Name Phone # P# Address Vendor ID # City, State, Zip Appointment Date I was appointed to serve as attorney or GAL This is a complete and accurate record of the services I rendered for . Name Estates Division CODE Deceased Estate with no funds Minor/Adult Conservatorship with no funds in Estate Minor/Adult Guardianship Minor/Adult Report Only (no hearing) DEC MIC/ADC MIG/LIP REP Fee Per Case $180 $180 $180 $100 Hearing Date(s) - not applicable - Other : DDP HOS JUR DEF FOR MIS Fee Per Case $300 $180 $250 $90 $200 $50 ADJ ADJ DEM DIS Mental Health Division $45 $45 $180 $180 CODE Developmentally Disabled Individual Commitment Hearing Jury Trial Deferral Forensic Hearing Ypsilanti Adjourned Hearing Independent Evaluation requested at time of hearing. When Not notified prior to hearing date Demand for Hearing Discharged Hearing Date(s) Other: Other – Estates and Mental Health Division Extraordinary Fees (PLEASE PROVIDE AN ITEMIZED EXPLANATION) Appeals - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ($500 max.) Excess Travel 50 to 74 Miles $25.00 $ Per Hour $60 $60 # Of Hours 75 to 99 Miles $37.50 Total 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 Please Return to: Circuit/Probate Judge OFFICE OF THE COURT ADMINISTRATOR OAKLAND COUNTY CIRCUIT COURT 1200 N. TELEGRAPH ROAD, DEPT. 404 PONTIAC, MI 48341-0404 Questions? Call Debbie Thompson (248) 858-0255 Fax: (248) 975-9877 PEMH 1092 (11/06) STATEMENT OF SERVICES AND ORDER FOR PAYMENT OF COURT APPOINTED ATTORNEY/GAL - PROBATE ORI MI-630013J American LegalNet, Inc. www.FormsWorkflow.com