MOTION, ENTRY, AND CERTIFICATION FOR APPOINTED COUNSEL FEESIn the, OhioCourt ofPlaintiff:Case No. Appellate Case No. (if app.) VSCapital Offense Case Guardian Ad LitemDefendant/Party Represented(check if this is a Capital Offense Case) (check if appointed GAL)Judge:In re:MOTION FOR APPROVAL OF PAYMENT OF APPOINTED COUNSEL FEES AND EXPENSESThe undersigned having been appointed counsel for the party represented moves this court for an order approving payment of fees and expenses as indicated in the itemized statement herein. I certify that i have received no compensation in connection with providing representation in this case other than that described in this motion or which has been approved by the Court in a previous motion, nor have any fees or expenses in this motion been duplicated on any other motion. I, or an attorney under my supervision, have performed all legal services itemized in this motion.COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.JUDICIAL SUBPOENAPlaintiff(s)appointed-against-. This case terminated and/or wasPeriodic Billing (Check here if Periodic Billing) As attorney/guardian ad litem of record, I wasondisposed of on. I am submitting this application onName:Signature:Address:Defendant(s). . . . . . . . . . . .City. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .SSN/Tax ID: OSC Reg. No:No. & StreetStateZip CodeSUMMARY OF CHARGES, HOURS, EXPENSES, AND BILLINGDISPOSITION DEGREE ORC/CITY CODEOFFENSE/CHARGE/MATTERTHE PEOPLE OF THE STATE OF NEW YORK TO1) 2)3)*List only the (3) three most serious charges beginning with the one of greatest severity and continuing in a descending order.GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorablePre-TrialAll Other In-Court,In-Court Totalout-of-courtGrand Total In-Court Grand Total Hours From Other Side:located at County ofHearings, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofTotal Fees ExpensesFlat Fee Min Fee$60.00$50.00X Rate X Rate=Hrs. In Hrs. OutTotalYour failure=to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.JUDGMENT ENTRYThis Court finds that counsel performed the legal services set forth on the itemized statement on the reverse hereof, and that the fees and expenses set forth on this statement are reasonable, and are in accordance with the resolution of the Board of County Commissioners of, one of the Justices of theCourt in Witness, Honorable, 20 County,day ofCounty, Ohio relating to payment of appointed counsel, that all rules and standards of the Ohio Public Defenders Commission and State Public Defender have been met.(Attorney must sign above and type name below)IT IS THEREFORE ORDERED that counsel fees and expenses be, and are hereby approved, in the amount of It is further ordered that the amount be, and hereby is, certified by the Court to the County Auditor for payment.Attorney(s) forExtraordinary fees granted (copy of journal entry attached)JudgeSignatureDateCERTIFICATIONOffice and P.O. AddressThe County Auditor, in executing this certification, attests to the accuracy of the figures contained herein. A subsequent audit by the Ohio Pubic Defender Commission and/or Auditor of the State which reveals unallowable or excessive costs may result in future adjustments against reimbursement or repayment of audit exceptions to the Ohio Public Defender Commission.Telephone No.: Facsimile No.: E-Mail Address:Warrent NumberWarrent DateCounty NumberCounty AuditorMobile Tel. No.:American LegalNet, Inc. www.USCourtForms.com