FORM JH-A1 (Rev. 2005) ATTORNEY JUDICIAL HOSPITALIZATION GUARDIAN AD LITEM (Please check one) IN S T R U C T IO N S : Form JH-A1 must be submitted in duplicate to the clerk of the court w ithin 180 days of final disposition of case, 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 County of Court Clerk IN THE MATTER OF Order entered day of , 20 Docket # Type of Proceeding: (Select one) Lim ited Guardianship/ Conservatorship SUMMARY OF ACTIVITY TOTALS (From itemized list on back of form) Em ergency Involuntary Com m itm ent (A) IN-COURT HOURS (TENTHS) @ $50.00 HR. Indefinite Involuntary Com m itm ent (B) OUT-OF-COURT HOURS (TENTHS) @ $40.00 HR. I ce rtify tha t the foregoing represen ts an accurate and com plete statem ent of tim e and expense in connection with the above action or proceeding and that these services were rendered, pursuant to m y appointm ent, in com pliance with Title 33, Chap. 3-8, Mental Health Law, Suprem e Court Rules13 and 15. (C) COPIES OR LONG DIST. CALLS ONLY OUT-OF-POCKET EXPENSE E nter FU LL N am e and C O M P LE T E Add ress H ere Attorney: Address: Signature of Attorney , TN Social Security No. (D) OTHER APPROVED EXPENSE ZIP Phone TO BE COM PLETED BY JUDGE AM OUNT 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 nam ed 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 tim e claim ed by said attorney as expended in this cause to be reasonable and recom m end said attorney be com pensated in com pliance with Suprem e Court Rules 13 and 15. This the day of , 20 . Signature of Judge Judge’s Nam e S Please Print American LegalNet, Inc. www.USCourtForms.com FORM JH-A1 (Rev. 2005) JUDICIAL HOSPITALIZATION ATTORNEY GUARDIAN AD LITEM (Please check one) IN THE MATTER OF Docket # Title 33, Chap. 3-8, Supreme Court Rule 13 ACTIVITY DATE OF ACTIVITY What legal services did you render? Itemize any out-ofpocket 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. (A) IN-COURT HOURS (TENTHS) @ $50.00 HR. (B) OUT-OFCOURT HOURS (TENTHS) @ $40.00 HR. (C) COPIES OR LONG DIST. CALLS ONLY OUT-OF POCKET EXPENSE (D) OTHER APPROVED EXPENSE 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. 2. The total compensation for any one proceeding shall not exceed $500.00. 3. All claims for compensation shall be specific as to the service performed, the date performed, time in hours and tenths of hours. 4. 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) 5. 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. 6. No co-counsel or associate attorney will be compensated. 7. 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 proceeding, so that the judge may make such apportionment between the attorneys as may be just. 8. 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. 9. 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. American LegalNet, Inc. www.USCourtForms.com