FORM JH-A1 (Rev. 2005) ATTORNEY JUDICIAL HOSPITALIZATION GUARDIAN AD LITEM (Please Check One) INSTRUCTIONS: Form JH-A1 must be submitted in duplicate to the clerk of the Court within 180 days of final disposition of case and both copies must be signed by the attorney and the judge. The clerk shall retain one copy and forward the original to the Director of the Administrative Office of the Courts, Nashville, TN 37219. ALL CLAIMS MUST COMPLY WITH THE RULES LISTED ON BACK STATE OF TENNESSEE Court: IN THE MATTER OF: Order entered day of , 20 . County of Clerk: Docket # Type of Proceeding: (Select one) Limited Guardianship/ Conservatorship SUMMARY OF ACTIVITY TOTALS (From itemized list on back of form) Emergency Involuntary Commitment (A) IN-COURT HOURS (TENTHS) @ $50.00 HR. (B) OUT-OF-COURT HOURS (TENTHS) @ $40.00 HR. Indefinite Involuntary Commitment (C) COPIES OR LONG DIST. CALLS ONLY OUT-OF-POCKET EXPENSE (D) OTHER APPROVED EXPENSE I certify that the foregoing represents an accurate and complete statement of time and expense in connection with the above action or proceeding and that these services were rendered, pursuant to my appointment, in compliance with Title 33, Chap. 3-8, Mental Health Law, Supreme Court Rules 13 and 15. Enter FULL Name and COMPLETE Address Here: Attorney: Address: ______________________________________________ Signature of Attorney Social Security No. , TN Phone: ZIP: TO BE COMPLETED BY JUDGE AMOUNT 1. Total approved in-court hours at $50.00 per hour..................................................................... $_____________ 2. Total approved out-of-court hours at $40.00 per hour................................................................ $_____________ 3. Total out-of-pocket expenses (copies or long distance calls only)................................................ $_____________ 4. Approved expenses (prior authorization MUST be attached)...................................................... $_____________ TOTAL ATTORNEY/GUARDIAN AD LITEM COSTS AUTHORIZED................. $_____________ I hereby certify that I appointed the above named attorney to represent the individual who is the subject of this proceeding; I have found said subject to be INDIGENT as defined by Tennessee Code Annotated § 33-1-101(14). I further find the time claimed by said attorney as expended in this cause to be reasonable and recommend said attorney be compensated in compliance with Supreme Court Rules 13 and 15. This the ________ day of _______________, 20____. ______________________________________________ Signature of Judge ______________________________________________ Judge's Name ­ Please Print American LegalNet, Inc. www.USCourtForms.com FORM JH-A1 (Rev. 2005) ATTORNEY IN THE MATTER OF: JUDICIAL HOSPITALIZATION GUARDIAN AD LITEM (Please Check One) Docket # (A) IN-COURT HOURS (TENTHS) @ $50.00 HR. (B) OUT-OFCOURT HOURS (TENTHS) @ $40.00 HR. (C) COPIES OR LONG DIST. CALLS ONLY OUT-OFPOCKET EXPENSE (D) OTHER APPROVED EXPENSE TITLE 33, CHAP. 3-8, SUPREME COURT RULE 13 ACTIVITY WHAT LEGAL SERVICES DID YOU RENDER? ITEMIZE ANY OUT-OF-POCKET EXPENSE. ITEMIZE ANY OTHER APPROVED EXPENSE & ATTACH TO THE BACK OF THIS CLAIM A CERTIFIED COPY OF THE COURT'S PRIOR APPROVAL OF SUCH EXPENSES. DATE OF ACTIVITY ATTORNEY TOTALS The following rules govern attorney reimbursement claims in judicial proceedings under Title 33, Chap. 3-8, Mental Health Law, Supreme Court Rules 13 and 15. 1. The maximum hourly rate for attorneys shall not exceed $50.00 per hour for time expended in judicial proceedings, with a total maximum not to exceed $100.00 for each day of in-court proceedings. The maximum hourly rate for attorneys for time reasonably spent in preparing for judicial proceedings shall not exceed $40.00 per hour. The total compensation for any one proceeding shall not exceed $500.00. All claims for compensation shall be specific as to the service performed, the date performed, time in hours and tenths of hours. Out-of-pocket expenses for long distance telephone calls and copying charges incident to the proceeding, shall be reimbursed according to procedures set out in Supreme Court Rule 13, Section 4. (i.e. 4 copies @ .07/copy) The order appointing counsel must be attached to the form before it can be processed. Those forms received which are not accompanied by the order will be returned. No co-counsel or associate attorney will be compensated. If any attorney is substituted for an attorney previously appointed for a party in the same case, the total compensation which may be paid both attorneys shall not exceed the statutory maximum of one proceeding. In such cases, compensation shall not be fixed by the judge until the conclusion of proceedings, so that the judge may make such apportionment between the attorneys as may be just. The form on the front must be completed and submitted in duplicate to the judge in compliance with instructions listed on front. After the form has been approved by the judge, it must be filed with the clerk. The clerk will retain one copy and forward the original to the Administrative Office of the Courts. This form should be used for attorneys and guardians ad litem appointed in proceedings brought by a superintendent of a state mental health facility pursuant to Title 34, Guardianship Law. See T.C.A. § 33-3-503. 2. 3. 4. 5. 6. 7 8. 9. American LegalNet, Inc. www.USCourtForms.com