CRIMINAL JUSTICE ACT COURT APPOINTED COUNSEL FORM 1. Name: 2. Firm Name: 3. Office Address: 4. County: 5. Office Telephone No: 6. Home Telephone No: 7. Social Security No: 8. Federal Tax Identification No: 9. Preference: Fax No: Felony _______ Misdemeanor _______ Petty _______ Comments: 10. Date of Admission to the Eastern District of Virginia: 11. Date of Admission to the State Bar: 12. Legal Experience: Bar No: A. Trial Experience (indicate state or federal) B. Appellate Experience: (indicate state or federal) C. Please List Any Other Pertinent Data Such As Specialty, Public Positions, Etc. 13. Have you completed any courses on the Sentencing Guidelines? G Yes GNo Date: Have you completed any courses on the Bail Reform Act? G Yes 14. GNo Date: I am fluent in a foreign language(s): G Yes GNo Specify: 2002 © American LegalNet, Inc. CJA VOUCHER INFORMATION VOUCHERS MUST BE SUBMITTED WITHIN 45 DAYS OF JUDGMENT 1. RATES: $75.00 $55.00 PER HOUR FOR IN COURT TIME PER HOUR FOR OUT OF COURT TIME (Work performed on or after April 1, 2001) $70.00 $50.00 PER HOUR FOR IN COURT TIME PER HOUR FOR OUT OF COURT TIME (Work performed prior to April 1, 2001) 2. MAXIMUMS ALLOWED: $1,500.00 $5,200.00 $1,200.00 NOTE: MISDEMEANDORS (EXCLUSIVE OF ALLOWABLE EXPENSES) FELONS (EXCLUSIVE OF ALLOWABLE EXPENSES) POST TRIAL MOTIONS, PROBATION OR PAROLE VIOLATION, ETC. (EXCLUSIVE OF ALLOWABLE EXPENSES) IF A CLAIM IS IN EXCESS OF THE MAXIMUM ALLOWED, AND COUNSEL IS REQUESTING PAYMENT IN EXCESS OF THE MAXIMUM, COUNSEL SHALL ATTACH TO THE VOUCHER A MEMORANDUM DETAILING THE SERVICES, WHICH SHALL BE IN BOTH NARRATIVE AND STATISTICAL FORM AS TO HOURS SPENT, AND SHALL PROVIDE JUSTIFICATION FOR HOURS SPENT. 3. RECORD OF SERVICES: PLEASE USE THE ATTACHED WORKSHEETS FOR IN COURT AND OUT OF COURT EXPENSES. MILEAGE RATE IS $.365 PER MILE. PLEASE INCLUDE TOLLS AND PARKING IN THIS SECTION. EXPENSES: PLEASE ITEMIZE AND SUBMIT RECEIPTS, IF APPROPRIATE. 2002 © American LegalNet, Inc. TO: FROM: COURT APPOINTED ATTORNEYS CLERK’S OFFICE, U.S. DISTRICT COURT In order to be compensated for your services in a timely manner, please follow the directions attached to the front of the vouchers, and use the hourly worksheets provided. You are responsible for filling in items 16A thru D, (where applicable), and 17 thru 21. The hours and dates must be filled in on items 17 and 18. Item 16A-D: Social Security Number/Employer Identification Number Each appointed attorney must supply his or her social security number. If the attorney has an agreement, in effect prior to the representation provided pursuant to the CJA, with his or her law firm or corporation, that CJA earnings belong to the law firm or corporation rather than to the attorney/payee (“preexisting agreement”); then the attorney must also supply the firms employer identification number. As required by the CJA, payment will be made to the appointed attorney. The appointed attorney is required to furnish his or her social security number and if applicable the law firm’s employer identification number so that the Administrative Office may file information returns with the Internal Revenue Service in accordance with 26 U.S.C. 6041. The authority for disclosure of the social security number and employer identification number is 26 U.S.C. 6109(a)(2) and 26 CFR 301.6109-1(c). Item 16A: If you have a preexisting agreement with a corporation, including a professional corporation, check the box “Yes”, leave Items 16B-D blank, and proceed directly to Item 17. If you do not have such a preexisting agreement with a corporation, check the box “No” and enter your social security number and your law firm’s employer identification number (if applicable) pursuant to the instructions below. Item 16B: Enter your social security number. Item 16C: Enter the law firm’s employer identification number if you have a preexisting agreement with a law firm (but not a corporation, including a professional corporation) that CJA earnings belong to the law firm. Item 16D: If the employer identification number has been provided in Item 16C, enter the name and mailing address of the law firm. 2002 © American LegalNet, Inc. IN COURT HOURLY WORKSHEET CASE _______________ VOUCHER _______________ PAGE ______ OF _____ DEFENDANT NAME: ________________________________ Date YR- Brief Description of Services Arraignment and/or Plea Motions and Requests Bail Hearings Sentencing Hearings Trial Revocation Hearings Appea ls Page Total Grand Total 2002 © American LegalNet, Inc. Other OUT OF COURT HOURLY WORKSHEET DEFENDANT NAME: ________________________________ Date YR- Brief Description of Services Interviews and Conferences Obtaining and Reviewing Legal Research Brief Writing CASE _______________ VOUCHER _______________ PAGE ______ OF _____ Travel Time Investigative and Other Work Page Total Grand Total 2002 © American LegalNet, Inc. OTHER EXPENSE WORKSHEET CASE _______________ VOUCHER _______________ PAGE ______ OF _____ DEFENDANT NAME: ________________________________ Date YR- Brief Description of Services Mileage Parking Meals Lodging Copying Postage Toll Ca lls Telegrams Page Total Grand Total 2002 © American LegalNet, Inc. Other