THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) STATEMENT FOR PAYMENT Attorney (ATTY) ATTY or GAL for: 1. Guardian Ad Litem (GAL) Respondent Father Mother Other Service Provider Child Proposed Ward Name of payee Address of payee Vendor number (If unknown, leave blank and AOC Accounting will complete.) 2. Name of Attorney, GAL or service provider if different from payee 3. If Attorney or GAL on this case, date of appointment by court (Attach copy of the order of appointment) 4. If Other Service Provider, date services authorized by the court Type of services authorized Amount authorized $ (Attach copy of the order authorizing service, if applicable) 5. Type of billing: Final Interim 6. Supplemental Billing Period: This statement is for the period beginning and ending 7. Billing Amount: (Attach itemization of all charges, including date, amount of time, rate.) SERVICE FEES Provider Total time Rate Cost Paralegal hours $35/hour $ Attorney hours $60/hour $ GAL hours $60/hour $ Other Provider hours $ _____/hour TOTAL $ TOTAL SERVICE FEES 8. TOTAL EXPENSES $ TOTAL OF THIS BILL EXPENSES (Attach itemization of all expenses.) $ $ Total of previous bills in this case: $ (Attach copy of order or notice of decision, if any, granting motion to exceed fee cap.) NHJB-2154-P (09/25/2009) (formerly AOC-409-003) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: STATEMENT FOR PAYMENT I represent that the foregoing is a true and reasonable bill for the services I rendered and for the costs incurred. I certify that I have not and will not receive any other compensation for the services or costs specified on the attached itemization. Date Provider Signature I hereby certify that I have examined the above statement and find the charge of $ reasonable. Date to be Presiding Judge Signature IMPORTANT REQUIREMENTS for filing statement with court Attorney or Guardian ad Litem Statements must be submitted to the court within 60 days of the disposition of the case, or within 60 days of being discharged, unless the presiding judge allows an extension of time for filing the statement due to extenuating circumstances. Other Service Provider Statements must be submitted to the court within 30 days of providing the authorized service. The following should be attached to this statement: 1. A copy of the order of appointment or order authorizing services, if applicable. 2. Itemization of all charges, including the date, amount of time and rate. 3. Itemization of all expenses, including a description of each expense and the cost of each expense. 4. A copy of the order or notice of decision, if any, granting a motion to exceed the fee cap related to the case. FOR COURT USE ONLY: CASE TYPE: NHJB-2154-P (09/25/2009) (formerly AOC-409-003) COURT CODE: Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com