COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : 9 Supreme Court 9 Court of Appeals STATE OF OREGON Appellate Court Case Number(s): Index No. : Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA COURT-APPOINTED COUNSEL : REQUEST FOR CERTIFICATION OF COMPENSATION, COSTS AND : EXPENSES -against- V. : Plaintiff 9 Defendant 9 Defendant(s) : ... ...... .... .... ......... Trial . . . . . . TRIAL. COURT: . . . . . .District. Court . . . Circuit Court . . . . . . . . . . . Court Case No(s): 1. of APPOINTMENT INFORMATION: 9 County 9 Client is: Appellant/Petitioner Respondent Counsel Vendor No: THE PEOPLE OF THE STATE OF NEW YORK Counsel Tax ID No: Name of Client: Appointed Counsel: Mailing Address: TO OSB No: Date Appointed: ORS Authority for Appointment: 2. CASE INFORMATION: ORS CA Disposition: Appointment Type: Date Argued/Submitted: Convictions on reconsideration: GREETINGS: Date: Date: 9 9 Death penalty cases only-billing: Final Not Final SC Disposition: Date: WE COMMAND YOU, If not final, what further service expected? that all business and excuses being laid aside, you and each of you attend before 3.the Honorable COMPENSATION, COSTS AND EXPENSES REQUESTED: at the Court FOR COURT USE ONLY Hours Worked Amount located at County of Court-Approved Amount* by .10 hours Rate Requested room on the day of , at $ o'clock in the noon, and at any recessed $ , 20 A.inATTORNEY TIME,(ATOA $ adjourned EXPENSES Quantity/Units B.orCOSTS AND date, to testify and give evidence as a witness in this action on the part of the $ $ $ $ $ $ $ $ $ $ $ Your 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 9 resultLIST ATTACHED; SUBTOTAL ALL COSTS AND EXPENSES of your failure to comply. C. TOTAL COMPENSATION, COSTS AND EXPENSES (A plus B) $ $ $ $ Witness, Honorable , one of the Justices of the I certify that the information in this request for certification, including any attachments, is true. I have not been promised, have Court in County, day compensation for, these services except as approved by the court or authorized 20 not received and will not accept direct or indirect of by contract under ORS 151.460. DATE SIGNATURE OF COUNSEL (Attorney must sign above and type name below) CERTIFICATION OF COMPENSATION, COSTS AND EXPENSES An order having been entered appointing counsel on the basis of a determination that the person for whom counsel was Attorney(s) for * is reasonable and necessary as compensation, costs and appointed is indigent, the court certifies that $ expenses and is properly payable out of state indigent defense funds. Office and P.O. Address DATE JUDGE JUDGES OSB NUMBER PRINT, TYPE OR STAMP NAME OF JUDGE Telephone No.: Facsimile No.: PTCF SUP/COA-100:10/9: 1-COURT APPOINTED COUNSEL REQUEST FOR CERTIFICATION OF COMPENSATION, COSTS AND EXPENSES E-Mail Address: Mobile Tel. No.: *IF THE AMOUNT APPROVED IS LESS THAN THE AMOUNT REQUESTED, SEE THE ATTACHED NOTICE OF DISALLOWED COMPENSATION, COSTS AND EXPENSES. EVT American LegalNet, Inc. www.USCourtForms.com ,