UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK DISTRICT COURT FUND EXPENSE REIMBURSEMENT VOUCHER _______________________________ vs. _________________________________ ______ CV ___________ I, ______________________________, duly appointed as counsel to represent _______________________________ in the above entitled action, pursuant to Local Rule of Civil Procedure 83.1 (m), hereby request reimbursement from the District Court Fund of the following expenses incurred in the representation of my client before this Court: Fees of the court reporter for transcripts or depositions necessary for the preparation of the case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________ Fees for investigative or expert services (with prior Court approval) . . . . . . . . . . . . . . . . . . $____________________ Travel expenses (with appropriate approval) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________ Fees for service of papers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________ Fees for witnesses (itemized with supporting documentation) . . . . . . . . . . . . . . . . . . . . . . . $____________________ Fees for interpreter services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________ Expenses of photocopies, photographs, postage, toll calls, telegrams, etc. necessary for the preparation of the case (itemized with supporting documentation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________ Other expenses (with prior Court approval if greater than $250; and itemized with supporting documentation) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $____________________ TOTAL $____________________ SPECIAL NOTE: Submit voucher and attach documentation for requested payments in all categories to: Clerk, U.S. District Court, 2 Niagara Square, Buffalo, NY 14202-3350. I certify that the expenses noted above are reasonable and necessary. I further understand that, absent extraordinary circumstances, cumulative expenses in this matter are limited to $1,800.00. If requesting reimbursement for more than $1,800.00, I acknowledge the requirement to provide an Affidavit stating the extraordinary circumstances and such Affidavit is attached hereto. Signature of Attorney: _______________________________________________ Date: ______________ Name of Attorney/Payee: _______________________________________________ Mailing Address: _______________________________________________ _______________________________________________ Payee's Social Security Number or Employer I.D. Number: ___________________ It is Ordered that payment from the District Court Fund be made in the amount of $____________________________. Signature of Presiding Judicial Officer: ______________________________________ For Use By Financial Section Only: Paid _______________ Initials__________ Rev. 09/2012 Date: ______________ American LegalNet, Inc. www.FormsWorkFlow.com