United States District Court District of New Hampshire CJA ATTORNEY PAYEE REGISTRATION Name: Social Security #: Telephone: ______________________ INDICATE BELOW HOW PAYMENTS SHOULD BE REPORTED TO THE IRS G Under my social security number and name, as indicated above OR G To the law firm with which I am affiliated. The law firm's taxpayer identification number, name, and address are: Taxpayer ID #: Law Firm Name: _________________________________________ Address: _________________________________________ _________________________________________ Attorney Signature: _______________________________ Date: __________________ USCDNH-23A (11/00)(Previous Editions Obsolete) American LegalNet, Inc. www.USCourtForms.com