MOTION, ENTRY, AND CERTIFICATION FOR APPOINTED COUNSEL FEES In the _________________________________________ Plaintiff: v. _________________________________________________ Defendant/Party Represented In re: _____________________________________________ Court of ________________________________________, Ohio Case No. _________________________________________ Appellate Case No. (if app.) ___________________________ Capital Offense Case (check if Capital Offense case) Guardian Ad Litem (check if appointed as GAL) Judge: ___________________________________________ 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. ________________ DEGREE DISPOSITION SUMMARY OF CHARGES, HOURS, EXPENSES, AND BILLING OFFENSE/CHARGE/MATTER ORC/CITY CODE 1.) 2.) 3.) *List only the three most serious charges beginning with the one of greatest severity and continuing in descending order. IN-COURT PRE-TRIAL HEARINGS ALL OTHER IN-COURT Grand Total Hours From Other Side: Flat Fee Min Fee Hrs:In OUT-OF-COURT IN-COURT TOTAL GRAND TOTAL __________ X Rate ________ X Rate ________ = $_____________ = $_____________ Tot. Fees $___________ Expenses $___________ Total $___________ Hrs:Out __________ 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 ______________________________________________ Date Signature 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: IN-COURT ALL OTHER IN-COURT IN-COURT ALL OTHER IN-COURT PRE-TRIAL HEARINGS DATE OF SERVICE OUT- OFCOURT TOTAL INCOURT TOTAL PRE-TRIAL HEARINGS DAILY TOTAL DATE OF SERVICE (continued) OUT- OFCOURT TOTAL 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. (3) Records/Reports (4) Transcripts (5) Travel (6) Other I hereby certify that the following expenses were incurred: Use the following categories for Type: (1) Experts (2) Postage/Phone TYPE PAYEE 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