United States District CourtNorthern District of OhioCJA Attorney Payee RegistrationName:Social Security #:Mailing Address:Email Address:Telephone:Please indicate below how payments should be reported to the IRS: (Select One Only) Under my social security number and name, as indicated aboveor To the law firm with which I am affiliated.The law firms taxpayer identification number, name and address are:TaxableIdentificationNumber (TIN):Law Firm's Name:Address:SignatureDate American LegalNet, Inc. www.FormsWorkFlow.com