FORM GA-1 (Rev. 2006) CLAIM FOR FEES FOR GUARDIAN AD LITEM OR ATTORNEY REPRESENTING PARENTS IN DEPENDENCY AND TERMINATION OF PARENTAL RIGHTS CASES (See Tennessee Supreme Court Rule 13 for Compensation Limits) INSTRUCTIONS: Type and submit in duplicate to the clerk of court. Both copies must be signed by the attorney and judge. Attach the signed order of appointment. The Clerk shall retain one copy for its files and shall forward the original to the Administrative Office of the Courts, Attorney Claims, Nashville City Center, Suite 600, 511 Union, Nashville, TN 37219. COUNTY OF COURT CHILDREN/NAMES, DOB & CORRESPONDING FILE NOS. (File Number remains the same for each claim submitted for this client(s). Only one claim may be filed for a sibling group. Must be completed by GAL and parent’s attorney.) PETITION NO.: REPRESENTATION: GUARDIAN AD LITEM PARENT’S ATTORNEY ATTORNEY (S.Ct. Rule 40 Appt.) Name of Parent(s) TYPE OF CASE: I. DEPENDENT/NEGLECT/ABUSE: II. TERMINATION OF PARENTAL RIGHTS Claim for Original Petition III. APPEAL TO CIRCUIT COURT Claim for Intervening Petition IV. APPEAL TO COURT OF APPEALS V. APPEAL TO SUPREME COURT (Attach Petition – Separate claim is permitted only if disposed of separately from original petition) CLAIM FOR FOLLOWING PHASE: Filing of N/D Petition to Disposition Post-disposition (Last date of activity______________________) (Foster care review boards, court reviews, permanency hearing) DATE OF DISPOSITION: HAVE YOU BILLED FOR THIS CLIENT PREVIOUSLY? SUMMARY OF ACTIVITY TOTALS (From itemized list on back of form) (A) IN-COURT HOURS (Tenths) (B) OUT-OF-COURT HOURS (Tenths) 0.0 TOTALS I certify that the foregoing represents an accurate and complete statement of time and expenses in connection with the above action or proceedings. YES NO (C) NECESSARY EXPENSES 0.0 $0.00 Enter FULL Name and Complete Address Here Attorney: __________________________________________ Address: __________________________________________ _______________________________________ __________________________________________________ Signature of Attorney City: _________________ State: ____ Zip _______________ Soc. Sec. No.: ___________________________ Phone: ____________________ Fax:___________________ Fed. Tax Id. No:_____________________________ TO BE COMPLETED BY JUDGE (A) ________ Total Approved In-Court Hours @ $50 Per Hour................................................. (B) ________ Total Approved Out-of-Court Hours @ $40 Per Hour.......................................... (C) ________ Total Approved Necessary Expenses ................................................................ TOTAL ......................... Subject to the provisions of T.C.A. § 37-1-150, the Court finds this to be reasonable compensation for work done in the above-style case. This the day of , Signature of Judge ___________________________________________ Judge’s Name — Please Print American LegalNet, Inc. www.FormsWorkflow.com ACTIVITY DATE Itemize in-court and out-of court hours spent working on this case. Itemize any out-of-pocket expense. Itemize any other approved expenses & attach to this claim a certified copy of the court=s prior approval of such expense. (A) IN-COURT HOURS (Tenths) (B) OUT-OF COURT HOURS (Tenths) (C) NECESSARY EXPENSES Once upon a time they lived happily ever after,111 Once upon a time the lived happily ever after.eeee TOTALS: 0.0 0.0 $0.00 American LegalNet, Inc. www.FormsWorkflow.com