New York State, Supreme Court Appellate Division, Third Judicial Department P.O. Box, 7288, Capitol Station Albany, New York 12224 In the Matter of CASE NO. VOUCHER FOR ASSIGNED COUNSEL (Family Court Appeal) Date of assignment Order or judgment appealed from Date record and briefs filed Date of argument of appeal (if submitted, so state) Date of Appellate Division decision VOUCHER MUST BE SUBMITTED WITHIN 60 DAYS FROM DATE OF DECISION. For legal services rendered by , with offices at , as counsel assigned to represent pursuant to section 1120 of the Family Court Act from to . Attach Itemized Statement of Services and Expenses American LegalNet, Inc. www.FormsWorkFlow.com Total Hours: (x $75) $ Fee Request: $ Disbursements: $ TOTAL FEE AND DISBURSEMENTS: $ Attorney's Certification of Claim , attorney-at-law, certifies under penalty of perjury, that I am the claimant herein; that the items of the above account in the amount of $ are true and correct; that the disbursements, services and supplies charged herein have in fact been made or rendered; that no part of the amount claimed has been paid or satisfied; that I have not sought, nor have I received, any fee or other compensation for representing the above-named person, nor have I sought or received any compensation in this case from any other source. DATED: Signature Print Name: Address: *NOTE. Itemized statements should show a breakdown of the time expended: (a) reviewing record, (b) preparing legal research, (c) preparing other work stating nature preliminary to preparation of brief and (d) preparing brief. While time expended is an important consideration in fixing fees, the Court also gives great weight to other factors such as the difficulty of the case, the diligence with which the assignment was completed, and the competence and skill of counsel in the performance of services. Please note that commencing January 1, 2004, the hourly rate for appellate court representation is $75. The limit on compensation without a showing of extraordinary circumstances is $4,400. Claims for payment above the statutory cap must be accompanied by an affidavit in support of the excess fee claim. Revised 4-2011 American LegalNet, Inc. www.FormsWorkFlow.com