MOTION, ENTRY, AND CERTIFICATION FOR APPOINTED COUNSEL FEES In the _________________________________________ Court of ________________________________________, Ohio Plaintiff: Case No. _________________________________________ ________________________________________________ v. _________________________________________________ Defendant/Party Represented Appellate Case No. (if app.) ___________________________ In re: _____________________________________________ Judge: ___________________________________________ Capital Offense Case (check if Capital Offense case) Guardian Ad Litem (check if appointed as GAL) MOTION FOR APPROVAL OF PAYMENT OF APPOINTED COUNSEL FEES AND EXPENSES The 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 and 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. Periodic Billing (check if this is a periodic bill) As attorney/guardian ad litem of record, I was appointed on ______________________, ________. This case terminated and/or was disposed of on ______________________,________. I am submitting this application on _________________________, ________. Name_____________________________________________ Signature________________________________________________ Address___________________________________________________________________ No. and Street City State Zip SSN/Tax ID____________________ OSC Reg. No. ________________ SUMMARY OF CHARGES, HOURS, EXPENSES, AND BILLING OFFENSE/CHARGE/MATTER ORC/CITY CODE DEGREE DISPOSITION 1.) 2.) 3.) *List only the three most serious charges beginning with the one of greatest severity and continuing in descending order. IN-COURT Grand Total Hours From Other Side: OUT-OF-COURT PRE-TRIAL HEARINGS ALL OTHER IN-COURT IN-COURT TOTAL GRAND TOTAL Flat Fee Hrs:In __________ X Rate ________ = $_____________ Tot. Fees $___________ Min Fee Hrs:Out __________ X Rate ________ = $_____________ Expenses $___________ Total $___________ JUDGMENT ENTRY The 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 ______________________________ County, Ohio relating to payment of appointed counsel, that all rules and standards of the Ohio Public Defender Commission and State Public Defender have been met. IT IS THEREFORE ORDERED that counsel fees and expenses be, and are hereby approved, in the amount of $________________. It is further ordered that the said amount be, and hereby is, certified by the Court to the County Auditor for payment. Extraordinary fees granted (copy of journal entry attached) Judge ______________________________________________ Signature Date CERTIFICATION The County Auditor, in executing this certification, attests to the accuracy of the figures contained herein. A subsequent audit by the Ohio Public 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. County Number ___________________ Warrant Number ___________________ Warrant Date ___________________ County Auditor ____________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com CASE NUMBER ______________________________ ATTORNEY/GAL ______________________________ IF CAPITAL OFFENSE CASE, LIST CO-COUNSEL'S NAME HERE: ____________________________________ ITEMIZED FEE STATEMENT I hereby certify that the following time was expended in representation of the defendant/party represented: INCOURT TOTAL DATE OF SERVICE (continued) DAILY TOTAL OUT- OFCOURT TOTAL ALL OTHER IN-COURT IN-COURT PRE-TRIAL HEARINGS OUT- OFCOURT TOTAL ALL OTHER IN-COURT DATE OF SERVICE PRE-TRIAL HEARINGS IN-COURT INCOURT TOTAL DAILY TOTAL GRAND TOTAL Continue at top of next column. Time is to be reported in tenth of an hour (6 minute) increments. I hereby certify that the following expenses were incurred: Use the following categories for Type: TYPE (1) Experts (2) Postage/Phone (3) Records/Reports (4) Transcripts PAYEE (5) Travel (6) Other AMOUNT TOTAL Clearly identify each expense and include a receipt for any expense over $1.00. See Section (P)(1)(c) for privileged information. American LegalNet, Inc. www.FormsWorkFlow.com