United States Court of Appeals for the Fourth Circuit Voucher for Printing Services in Court-Assigned Cases In Case/Matter Of (Case Name) Appeals Docket Number Request and Authorization for Printing Services Attorney's Statement Full Name of Person Represented: Date of Assignment: As the attorney for the person represented who is named above, I hereby affirm that the services requested were necessary for adequate representation. I hereby request approval for services already obtained. Signature of Court-Assigned Attorney Claimant's Certification Payee's Name, Mailing Address, and Telephone Number Amount Claimed: $ Date of Service: Description of Service: Date I hereby certify that the attached invoice is correct and that I have NOT claimed or received payment from any other source for the services rendered and claimed on this voucher. Signature of Claimant/Payee Approved for Payment - Court Use Only Date Financial eligibility of the person represented having been established to the Court's satisfaction, the authorization requested is hereby granted. $ Signature of Chief Judge, Court of Appeals (or delegate) Amount Approved Date American LegalNet, Inc. www.USCourtForms.com