UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA ARBITRATOR'S CLAIM FOR COMPENSATION CASE NO.: _________________________ HEARING DATE(S): _______________________ CASE CAPTION: ______________________________________________________________ COMPENSATION RATE: _______ SINGLE ARBITRATOR - $250.00 PER DAY _______ PANEL ARBITRATOR - $100.00 PER DAY APPLICABLE RATE _____________ FOR _____________ HEARING DAY(S). ARBITRATOR COMPENSATION TRAVEL AND OTHER EXPENSES 1. Number of miles ______________ at ______ per mile $_______________ (Calculate mileage from residence/office to hearing location and return; For current mileage reimbursement rate, go to www.gsa.gov and search "mileage reimbursement") 2. Meals (Attach receipts) 3. Lodging expenses (Attach receipts) 4. Miscellaneous expenses (i.e. Parking, etc.; Attach receipts) $_______________ $_______________ $_______________ $_______________ TOTAL ARBITRATOR COMPENSATION $___________________ ___________________________________ ARBITRATOR'S NAME (Please Print) ____________________________________ SOCIAL SECURITY OR TAX ID NO. ______________________________________________________________________________ ADDRESS CITY STATE ____________________________________ SIGNATURE ===================================================================== Approved for payment by: __________________________________ Deputy Clerk ___________________________________ Date of Approval American LegalNet, Inc. www.FormsWorkFlow.com