IN THE WARREN COUNTY, OHIO COMMON PLEAS COURT PROBATE DIVISION PLAINTIFF/PETITIONER: v. DEFENDANT/RESPONDENT: IN RE: 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 any 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 disposed of on Name Address No. and Street City State Zip CASE NO: . This case was terminated and/or was . . I am submitting this application on Signature OSC Reg. No. SSN/TAX ID No. Case Type Mentally Ill Adult Protective Services Guardianship Guardian ad Litem Other Client's Name Party Designation Respondent Respondent *List only the three most serious charges beginning with the one of greatest severity and continuing in descending order. Grand Total Hours From Other Side: Hrs: In Hrs: Out OUT-OF-COURT PRE-TRIAL HEARINGS IN-COURT ALL OTHER IN-COURT IN-COURT TOTAL GRAND TOTAL X Rate X Rate =$ =$ Tot. Fees $ 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. 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 WCPC Form 26 Eff. 04/04/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO: ATTORNEY/GAL: ITEMIZED FEE STATEMENT I hereby certify that the following time was expended in representation of the party represented: IN-COURT ALL OTHER IN-COURT PRE-TRIAL HEARINGS PRE-TRIAL HEARINGS IN-COURT ALL OTHER IN-COURT DATE OF SERVICE OUT-OFCOURT TOTAL IN-COURT TOTAL DAILY TOTAL DATE OF SERVICE (continued) OUT-OFCOURT TOTAL IN-COURT 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: (1) Experts, (2) Postage/Phone, (3) Records/Reports, (4) Transcripts, (5) Travel, (6) Other TYPE PAYEE AMOUNT Clearly identify each expense and include a receipt for any expense over $1.00. See Section (P)(1)(c) for privileged information. WCPC Form 26.0 Eff. 04/04/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com