SUPREME, SUPERIOR, AND DISTRICT COURTS REQUEST FOR PAYMENT FOR INDIGENT DEFENSE SERVICES All information must be typed. Attorney ID Number:___________________ Court: ____________________ Case Numbers: ____________________ ____________________ Client Name: ____________________ Attorney Name: _________________________ Judge Requesting Appointment: ____________ 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- Supreme Court Appeal ($75/hr, up to $3000) [ ] 905- Misdemeanor ($50/hr up to $1500) [ ] 902- Murder ($100/hr, up to $15000) [ ] 907- Fines/Costs/Restitution ($50/hr up to $1500) [ ] 903- Class I Felony ($90/hr, up to $10000) [ ] 906- Other:________________ [ ] 904- Class II Felony ($60/hr, up to $5000) Hours must be rounded to nearest 1/10. Time over one hour must be specified (e.g. 9:15-10:30 a.m.). Summary of in and out of court time must be provided. In-court time must include the type of hearing (e.g. trial). Attach additional forms if necessary. Compensation for time exceeding the above thresholds must be approved in advance by the Chief or Presiding Judge. DATE 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 CERTIFICATION: I 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