OCJA 20 APPOINTMENT OF AND AUTHORITY TO PAY COURT APPOINTED COUNSEL (Rev. 12/03) 1. CIR./DIST./ DIV. CODE 2. PERSON REPRESENTED VOUCHER NUMBER 3. MAG. DKT./DEF. NUMBER 4. DIST. DKT./DEF. NUMBER 5. APPEALS DKT./DEF. NUMBER 6. OTHER DKT. NUMBER 7. IN CASE/MATTER OF (Case Name) 8. PAYMENT CATEGORY 9. TYPE PERSON REPRESENTED 10. REPRESENTATION TYPE GFelony GPetty Offense GAdult Defendant GAppellant (See Instructions) GMisdemeanor GOther GJuvenile Defendant GAppellee GAppeal GOther 11. OFFENSE(S) CHARGED (Cite U.S. Code, Title & Section) If more than one offense, list (up to five) major offenses charged, according to severity of offense.12. ATTORNEYS NAME (First Name, M.I., Last Name, including any suffix) ,13. COURT ORDER AND MAILING ADDRESS GO Appointing Counsel GC Co-Counsel GF Subs For Federal Defender GR Subs For Retained Attorney GP Subs For Panel Attorney GY Standby Counsel Prior Attorneys Name: Appointment Dates: GBecause the above-named person represented has testified under oath or has otherwise Telephone Number : satisfied this Court that he or she (1) is financially unable to emoypl counsel and (2) does not wish to waive counsel, and because the intersts ofe justice so require, the attorney whose14. NAME AND MAILING ADDRESS OF LAW FIRM (Only provide per instructions)name appears in Item 12 is appointed to represent this person in this case, OR GOther (See Instructions) Signature of Presiding Judge or By Order of the Court Date of Order Nunc Pro Tunc Date Repayment or partial repayment ordered from the person represented for this service at time appointment. GYES GNO CLAIM FOR SERVICES AND EXPENSES FOR COURT USE ONLY TOTAL MATH/TECH. MATH/TECH. HOURS ADDITIONAL CATEGORIES (Attach itemization of services with dates) AMOUNT ADJUSTED ADJUSTED CLAIMED REVIEW CLAIMED HOURS AMOUNT 15. a. Arraignment and/or Plea b. Bail and Detention Hearings c. Motion Hearings d. Trial e. Sentencing Hearings f. Revocation Hearings tr CouIn g. Appeals Court h. Other (Specify on additional sheets) (RATE PER HOUR = $ ) TOTALS: 16. a. Interviews and Conferences b. Obtaining and reviewing records c. Legal research and brief writing d. Travel time e. Investigative and other work (Specify on additional sheets) Out of Court (RATE PER HOUR = $ ) TOTALS: 17. Travel Expenses (lodging, parking, meals, mileage, etc.) 18. Other Expenses (other than expert, transcripts, etc.) GRAND TOTALS (CLAIMED AND ADJUSTED): 19. CERTIFICATION OF ATTORNEY/PAYEE FOR THE PERIOD OF SERVICE 20. APPOINTMENT TERMINATION DATE 21. CASE DISPOSITION IF OTHER THAN CASE COMPLETION FROM: TO: 22. CLAIM STATUS GFinal Payment GInterim Payment Number GSupplemental Payment Have you previously applied to the court for compensation and/or reimbursement for thisG YESGNOIf yes, were you paid?G YESGNO Other than from the Court, have you, or to your knowledge has anyone else, received paym(compensation or anything of value)ent from any other source in connection with this representation?G YES GNO If yegive details on additional sheets. s, I swear or affirm the truth or correctness of the above statements. Signature of Attorney Date APPROVED FOR PAYMENT COURT USE ONLY 23. IN COURT COMP. 24. OUT OF COURT COMP.25. TRAVEL EXPENSES 26. OTHER EXPENSES 27. TOTAL AMT. APPR./CERT.28. SIGNATURE OF THE PRESIDING JUDGE DATE 28a. JUDGE CODE 29. IN COURT COMP. 30. OUT OF COURT COMP.31. TRAVEL EXPENSES 32. OTHER EXPENSES 33. TOTAL AMT. APPROVED34. SIGNATURE OF CHIEF JUDGE, COURT OF APPEALS (OR DELEGATE) Payment approvedDATE 34a. JUDGE CODE in excess of the statutory threshold amount. American LegalNet, Inc. www.USCourtForms.com