FAMILY COURT REQUEST FOR PAYMENT FOR INDIGENT DEFENSE SERVICES All information must be typed. Attorney ID Number:______________________ Case Name:_____________________________ Case Number:___________________________ Petition Number(s):_______________________ __________ _____________ Attorney Name:______________________ Client Name:______________________ __ Appointment Date: ____ _______________ Disposition Date: _____________________ Disposition Judge: ____________________ PAYMENT TO BE MADE TO ME. [ ] Social Security Number: ___________________ Address:________________________________ _______________________________________ Telephone No:__________________ PAYMENT TO BE MADE TO MY FIRM. [ ] Federal ID Number: __________________ Name/Address:______________________ __________________________________ Telephone No:_______________________ CHECK TYPE OF REPRESENTATION: [ ] 901- Wayward/Delinquency ($30/hr, up to $1000) [ ] 905- TPR ($30/hr, up to $1500) [ ] 902- GAL/Child ($30/hr) [ ] 906- Adult Criminal ($35/hr, up to $2,500) [ ] 910- GAL/Adult ($30/hr) [ ] 907- Waiver/Jury Trial ($35/hr, up to $2,500) [ ] 903- Dependency/Neglect/Abuse ($30/hr, up to $1000) [ ] 908- Child/Spousal Support ($30/hr) [ ] 904- Review ($60 flat fee) [ ] 909- Other: _______________ Hours must be rounded to nearest 1/10. Time over one hour must be specified (e.g. 9:15-10:30 a.m.). A summary of in and out of court time must be provided. In-court time must include the type of hearing (e.g. trial). Reviews are compensated at a flat fee of $60. Arraignments are compensated at $30 per hour up t0 $100 for multiple arraignments. Attach additional forms if necessary. Compensation for time exceeding the above thresholds must be approved in advance by the Chief Judge. DATE (court dates first) HOURS EXPLANATION (give detail for out of court time and type of court hearing) TOTAL HOURS = Expenses—Cost for service of process and transcripts will be reimbursed. Indicate date, type of expense, and amount. TOTAL $________________________________ BILL SUMMARY: Total Hours_________ X $_________ = $__________ + __________ = $___________ Rate Expenses Total Bill TOTAL BILLED FOR THIS CASE TO DATE (INCLUDING THE CURRENT REQUEST FOR PAYMENT): $_________ THIS IS THE FINAL BILL: [ ] YES [ ] NO CERTIFICATION: I do certify that I have provided the services and incurred the costs described and that I have not, nor will I, accept any other payment for these services or expenses. Signature: __________________________________________ Date: ______________________ Approved by: _______________________________________ Date: _______________________ * Attorneys are responsible for providing two signed copies of this form – one for the court file and one for the Supreme Court. 4/05 American LegalNet, Inc. www.USCourtForms.com