Approved, SCAO Original - Court (white) 1st copy - MAACS (yellow) 2nd copy - Attorney (pink) STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address MAACS STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT APPOINTED COUNSEL (Page 1) CASE NO. Court telephone no. INSTRUCTIONS This form is designed to serve as both the voucher for fees in appellate assigned cases and the case summary attorneys are required to submit to the Michigan Appellate Assigned Counsel System under section 4(6)(c)(ii) of the regulations governing that system. The form should be completed as follows: 1. The attorney, upon completing all work within the scope of the order of appointment (whether that order was for representation in the Court of Appeals or the Supreme Court), should fill out all applicable lines of section I. Apart from basic background information, section I primarily seeks information about the case not readily available from such other sources as appellate court docket entries. 2. The attorney should fill out the fee and expense information in section II completely, then sign and date the declaration. The attorney should leave sections III and IV blank. 3. The attorney should then provide the entire form, with all copies intact, to the trial judge who signed the order of appointment. Counsel may wish to photocopy the form before filing it in case the original is lost. 4. The assigning judge should review the case summary, indicate in section III the fees and expenses actually being approved, and sign and date the form. 5. The court should keep the white copy, return the pink copy to the attorney, and forward the yellow copy to: Michigan Appellate Assigned Counsel System 1375 S. Washington Suite 300 Lansing, MI 48913 I. CASE INFORMATION 4. Address 5. Case name 9. Date appointed 14. 10. County 1. Attorney name 2. Bar no. 3. Telephone no. 6. Lower court no. 11. Judge OFFENSE(S) Include MCL cite 7. Court of Appeals no. 12. Case type: Bench Prob. viol. SENTENCES 8. Supreme Court no. 13. Transcript length (all transcripts) pp. Plea Jury 15. Client Visit: Date Location Client no. 16. Trial court motion/type: Date Result Result Result 17. Date of stipulation to dismiss 20. Court of Appeals oral argument: 18. Date of motion to withdraw as counsel If held, date and location 19.Resentencing/Evidentiary Date hearing: 21. Disposition: Date Not held CC 400 (10/02) Held MAACS STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT APPOINTED COUNSEL, Page 1 American LegalNet, Inc. www.FormsWorkFlow.com Approved, SCAO Original - Court (white) 1st copy - MAACS (yellow) 2nd copy - Attorney (pink) STATE OF MICHIGAN JUDICIAL CIRCUIT COUNTY Court address MAACS STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT APPOINTED COUNSEL (Page 2) CASE NO. Court telephone no. II. FEE INFORMATION SERVICES RENDERED Itemize on additional sheet if needed HOURS ACTUAL EXPENSES 1. Record review (transcript, court file, PSR/SIR) . . . . 2. Client visit (including travel) . . . . . . . 3. Other client contact. . . . . . . . . . . . . Trial court motions (prepare, appear): 4. new trial . . . . . . . . . . . . 5. withdraw plea . . . . . . . . 6. resentencing. . . . . . . . . 7. Evidentiary hearing (prepare, appear) . . . . . . . . . . . . . . 8. Resentencing (prepare, appear) . . . 9. COA leave application. . . . . . . . . . . 10. COA motion to remand . . . . . . . . . . 11. COA brief on appeal (research, write) 12. COA oral argument (prepare, appear, travel) . . . . . . . . . 13. COA motion for rehearing . . . . . . . . 14. Reply to prosecutor's S Ct appl. . . . 15. S Ct leave application . . . . . . . . . . . 16. S Ct brief on leave granted . . . . . . . 17. S Ct oral argument . . . . . . . . . . . . . 18. Administrative* 19. Other 21. 22. 23. 24. 25. 26. miles x �/mile $ Client visit �/mile $ miles x Oral argument pages x �/page $ Photocopying Postage . . . . . . . . . . . . . . . . . . . . $ Phone calls . . . . . . . . . . . . . . . . . . $ Other (itemize) . . . . . . . . . . . . . . . . . $ 27. TOTAL EXPENSES: $ REQUEST FOR PAYMENT 28. Fee requested . . . . . . . . . . . . . . 29. Expenses requested . . . . . . . . . . $ $ 30. TOTAL AMOUNT REQUESTED $ BASIS OF REQUEST 31. 32. 35. Fee schedule Hourly 33. Rate/hour . . . . . . . . . . . . . . $ 34. Maximum allowed (if applicable) $ Motion for extraordinary fees (attach copy) I declare that I was appointed by the court to serve as appellate counsel for the named defendant, and that above is a true statement of uncompensated services rendered and expenses incurred by me in the conduct of that appeal to the best of my information, knowledge, and belief. Date 20. TOTAL HOURS: *e.g. correspondence, filing claim, procuring records and transcripts, housekeeping motions, transmitting records to client or substitute counsel. Attorney signature III. ORDER FOR PAYMENT I certify that the above attorney was appointed to represent the named defendant, and the service was rendered. IT IS ORDERED the City/County of $ Date pay the above attorney $ in fees and in expenses, for a total of $ in compensation for all time and expense in connection with this case. Judge Bar no. IV. COURT USE ONLY CC 401 (12/88) MAACS STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT APPOINTED COUNSEL, Page 2 American LegalNet, Inc. www.FormsWorkFlow.com