CJA 31 DEATH PENALTY PROCEEDINGS: EX PARTE REQUEST FOR AUTHORIZATION AND VOUCHER FOR EXPERT AND OTHER SERVICES (Rev. 08/12) 1. CIR./DIST./ DIV. CODE 2. PERSON REPRESENTED VOUCHER NUMBER 3. MAG. DKT./DEF. NUMBER 7. IN CASE/MATTER OF (Case Name) 4. DIST. DKT./DEF. NUMBER 5. APPEALS DKT./DEF. NUMBER 6. OTHER DKT. NUMBER ' Adult Defendant ' Habeas Petitioner ' Appellant 8. TYPE PERSON REPRESENTED ' Appellee ' Other (Specify) ' D1 28 U.S.C. § 2254 Habeas (Capital) ' D4 Other (Specify) ' D2 Federal Capital Prosecution ' D7 State Clemency ' D3 28 U.S.C. § 2255 (Capital) ' D8 Federal Clemency 9. REPRESENTATION TYPE 10. 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. 11. ATTORNEY'S STATEMENT As the attorney for the person represented, who is named above, I hereby affirm that the services requested are necessary for adequate representation. I hereby request: OR ' Authorization to obtain the service. Estimated Compensation and Expenses: Z ' Approval of services already obtained to be paid for by the United States pursuant to the Criminal Justice Act. (See Instructions) Signature of Attorney ATTORNEY'S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS Date REQUEST AND AUTHORIZATION FOR EXPERT SERVICES ' Panel Attorney ' Retained Attorney ' Pro-Se ' Legal Organization 12. DESCRIPTION OF AND JUSTIFICATION FOR SERVICES (See Instructions) 01 ' Investigator 17 ' Hair/Fiber Expert 02 ' Interpreter/Translator 18 ' Computer (Hardware/ 03 ' Psychologist Software/Systems) 04 ' Psychiatrist 19 ' Paralegal Services 05 ' Polygraph 20 ' Legal Analyst/Consultant 14. COURT ORDER Financial eligibility of the person represented having been established to the Court's 06 ' Documents Examiner 21 ' Jury Consultant satisfaction, the authorization requested in Item 11 is hereby granted. 07 ' Fingerprint Analyst 22 ' Mitigation Specialist 08 ' Accountant 23 ' Duplication Services Signature of Presiding Judge or By Order of the Court 24 ' Other (Specify) 09 ' CALR (Westlaw/Lexis, etc.) 10 ' Chemist/Toxicologist 11 ' Ballistics 25 ' Litigation Support Date of Order Nunc Pro Tunc Date Services 13 ' Weapons/Firearms/Explosive Expert 14 ' Pathologist/Medical Examiner 26 ' Computer Forensics Repayment or partial repayment ordered from the person represented for this service at time of authorization. 15 ' Other Medical Expert 16 ' Voice/Audio Analyst ' YES ' NO Check the box which corresponds to the stage of the proceeding during which the work claimed at Item 16 was performed even if the work is intended to be used in 15. STAGE OF PROCEEDING connection with a later stage of the proceeding. CHECK NO MORE THAN ONE BOX. Submit a separate voucher for each stage of the proceeding. CAPITAL PROSECUTION HABEAS CORPUS OTHER PROCEEDING a. e. ' Appeal g. k. ' Petition for the l. o. ' Other (Specify) ' Pre-Trial ' Habeas Petition ' Stay of Execution b. f. ' Petition for the gg. ' State Court Appearance U.S. Supreme Court m. ' Trial ' Appeal of Denial of Stay ' Sentencing ' Evidentiary Hearing ' Petition for Writ of U.S. Supreme Court h. Writ of Certiorari n. p. ' Clemency c. d. Writ of Certiorari i. Certiorari to the U.S. ' Other Post Trial ' Dispositive Motions ' Appeal Supreme Court Regarding j. Denial of Stay CLAIM FOR SERVICES AND EXPENSES 16. SERVICES AND EXPENSES (Attach itemization of services with dates) a. Compensation AMOUNT CLAIMED FOR COURT USE ONLY MATH/TECHNICAL ADJUSTED AMOUNT ADDITIONAL REVIEW Telephone Number: 13. TYPE OF SERVICE PROVIDER (See Instructions) b. Travel Expenses (lodging, parking, meals, mileage, etc.) c. Other Expenses 17. PAYEE'S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS TIN: Telephone Number: CLAIMANT'S CERTIFICATION FOR PERIOD OF SERVICE FROM CLAIM STATUS TO GRAND TOTALS (CLAIMED AND ADJUSTED): ' Final Payment ' Interim Payment Number ' Supplemental Payment Date Date I hereby certify that the above claim is for services rendered and is correct, and that I have not sought or received payment (compensation or anything of value) from any other source for these services. Signature of Claimant/Payee 18. CERTIFICATION OF ATTORNEY I hereby certify that the services were rendered for this case. Signature of Attorney 19. TOTAL COMPENSATION 23. ' APPROVED FOR PAYMENT -- COURT USE ONLY 20. TRAVEL EXPENSES 21. OTHER EXPENSES 22. TOTAL AMOUNT APPROVED/CERTIFIED ' Either the total cost (excluding expenses) of all services combined does not exceed $800, or prior authorization was obtained; OR In the interest of justice the Court finds that timely procurement of these necessary services could not await prior authorization, even though the cost (excluding expenses) exceeds $800. Signature of Presiding Judge 25. TRAVEL EXPENSES Date 26. OTHER EXPENSES Judge Code 27. TOTAL AMOUNT APPROVED 24. TOTAL COMPENSATION 28. FOR REPRESENTATIONS COMMENCED AND APPELLATE PROCEEDINGS IN WHICH AN APPEAL IS PERFECTED ON OR AFTER APRIL 24, 1996, A. B. Total compensation and expense payments approved to date (include amounts withheld for interim payments) for investigative, expert and other services for this representation is $ Payment approved (compensation and expenses) in excess of the statutory threshold for investigative, expert and other services under 18 U.S.C. § 3599(g)(2). Signature of Chief Judge, Court of Appeals (or Delegate) Date Judge Code American LegalNet, Inc. www.FormsWorkFlow.com