Court-Assigned Counsel Voucher
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Court-Assigned Counsel Voucher Form. This is a Official Federal Forms form and can be use in 4th Circuit Court Of Appeals Circuit Court Of Appeals.
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UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
COURT-ASSIGNED COUNSEL VOUCHER
Appeals Docket No.
In The Case Of (Short Caption)
Person Represented (Full Name)
Date of Assignment
Full Name of Attorney
Mailing Address, Including Firm Name
Social Security/Employer Identification No.
City, State and Zip Code
' Check here if payment should be made to attorney and
reported under attorney’s social security number
' Check here if payment should be made to law firm and
reported under the firm’s employer identification number
CLAIMED COMPENSATION
CLAIMED EXPENSES
“In-Court”
“Travel”
“Out-of-Court”
“Other”
CLAIMANT’S CERTIFICATION
For period
to
I hereby certify that the above claim is correct and that I have not claimed or received payment from any other source for the
services rendered and claimed.
Signature of Attorney
Date
APPROVED FOR PAYMENT
(To Be Completed By Court Personnel Only)
Out-of-Court
Approved
In-Court Approved
$
$
Signature of Chief Judge (or designate)
Travel Expenses
Approved
$
Other Expenses
Approved
$
Total Amount
Approved
$
Date
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