FAMILY COURT INVOICE FOR GUARDIAN AD LITEM Guardian Ad Litem Appointed on Behalf of: Adult committed to Mental Health Facility / Name of Client: Name of Client: Name of Client: Payment Information: Name of Person or Firm: Address for remittance: Phone (home): Phone (work): Case Information: County: Judge: Petitioner: Respondent: FEE TOTALS GAL Service of: Child(ren) (428)(429) / Incarcerated Adult (352)(353) / Incompetent Adult (350)(351) / Civil Action No. Fax: E-mail: Social Security or FEIN: Child(ren) / Incarcerated Adult / Incompetent Adult / Active Military Personnel Client's Birth Date: Client's Birth Date: Client's Birth Date: Active Military Service Personnel(372)(373) / Fees Claimed: Mileage Claimed: Out of Pocket Expenses (attach receipts): Total Claim for Proceeding: (Fees) Not to exceed $3,000.00 (7-1-2012) Adult committed to Mental Health Facility(354)(351) / $ $ $ $ *AFFIRMATION - I hereby affirm that the above statements are true and correct and that during the time the charges occurred my appointment did not automatically end due to change in eligibility status of the client. Attorney Signature: __________________________________ (Must be in blue ink) Administrative Office use only: Approved: __________________________________________ SCA-F-405 Rev. 07/2012 Family Court Invoice for Guardian Ad Litem Date: ________________________________ Date: ________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 4 Attorney Name: Case No.: County: I. THE FOLLOWING SERVICES WERE RENDERED IN THIS PROCEEDING: TIME CODE CLASSIFICATIONS In Court - $100.00/hour H - Hearings W - Waiting in Court O - Other Out-of-Court - $80.00/hour D - Driving or Travel C - Conference with Client or Witness R - Research, preparation of pleadings I - Investigation O - Other (must specify) Itemized time must be in tenths of an hour. Date Time Code Attorney Time In-Court Attorney Time Location of Activity; Further Explanations, Notes, Out-of-Court or Comments Total: TOTAL FEES CLAIMED FOR THE ABOVE PROCEEDING Enter grand total from above chart. Total Due: Attach additional sheets if necessary. I have attached additional time sheet(s). The Administrative Office will return any Invoice with mathematical or other errors. If returned, you will need to obtain a corrected Order Approving Payment from the Judge. SCA-F-405 Rev. 07/2012 Family Court Invoice for Guardian Ad Litem American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 Attorney Name: II. Case No.: County: ALLOWABLE MILEAGE EXPENSES Please use the applicable I.R.S. promulgates standard mileage rate for business miles driven. Multiply by Rate X X X X X Totals: ONLY ONE ITEM PER LINE - Use additional mileage sheets, if necessary, and indicate additional mileage sheets below. Date MM/DD/YY From City To City Mileage Purpose Total TOTAL MILEAGE EXPENSES CLAIMED FOR THE ABOVE PROCEEDING Enter total cost from above chart Please enter the following amounts below and also on on page 1 of this voucher. Total service fees claimed for this proceeding Total service fees claimed from additional pages Total Out-of-Pocket Expenses (attach receipts) Total mileage claimed for this proceeding INVOICE GRAND TOTAL Attach additional sheets if necessary. I have attached $ $ $ $ $ additional mileage sheet(s). $ The Supreme Court will not reimburse Guardians Ad Litem for office expenses including, but not limited to: longdistance telephone calls, postage, invoice preparation time, paralegal/secretarial services and copying expenses. REMITTANCE INSTRUCTIONS: Attorneys: Please submit completed Invoice to Family Court Judge's office. Family Case Coordinator or Secretary Clerk: Please submit original Invoice and Order Approving Payment to the Clerk of the Circuit Court. Circuit Clerk: Please attach the original Invoice to a certified Order Approving Payment, including embossed seal and submit both to: WV Supreme Court of Appeals Family Court Program Coordinator 1900 Kanawha Blvd. E. Building 1, Room E-100 Charleston, WV 25305 SCA-F-405 Rev. 07/2012 Family Court Invoice for Guardian Ad Litem American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Attorney Name: I. ADDITIONAL TIME SHEET: Itemized time must be in tenths of an hour. Date Time Code Attorney Time In-Court Case No.: County: Attorney Time Location of Activity; Further Explanations, Notes, Out-of-Court or Comments Total: TOTAL FEES CLAIMED FOR THE ABOVE PROCEEDING Enter grand total from above chart. (Add to Total Due on Pages 1 and 3) Total Due: Page 4 of 4 Check this box to add a continuation sheet. SCA-F-405 Rev. 07/2012 Family Court Invoice for Guardian Ad Litem American LegalNet, Inc. www.FormsWorkFlow.com Attorney Name: J. ADDITIONAL TIME SHEET (continued): Itemized time must be in tenths of an hour. Date Time Code Attorney Time In-Court Case No.: County: Attorney Time Location of Activity; Further Explanations, Notes, Out-of-Court or Comments Total: TOTAL FEES CLAIMED FOR THE ABOVE PROCEEDING Enter grand total from above chart. (Add to Total Due on Pages 1 and 3) Total Due: Check this box to add a continuation sheet. SCA-F-405 Rev. 07/2012 Family Court Invoice for Guardian Ad Litem American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 4 Attorney Name: J. ADDITIONAL TIME SHEET (continued): Itemized time must be in tenths of an hour. Date Time Code Attorney Time In-Court Case No.: County: Attorney Time Location of Activity; Further Explanations, Notes, Out-of-Court or Comments Total: TOTAL FEES CLAIMED FOR THE ABOVE PROCEEDING Enter grand total from above chart. (Add to Total Due on Pages 1 and 3) SCA-F-405 Rev. 07/2012 Family Court Invoice for Guardian Ad Litem Total Due: Page 6 of 4 American LegalNet, Inc. www.FormsWorkFlow.com