COURT-FUNDED INVOICE PARENTING PLAN HOME STUDY EVALUATOR PAYMENT INFORMATION FUND 1759 Return ORIGINAL to: Pepper Flenner WV Supreme Court 1900 Kanawha Boulevard East Building. 1, Room E-100 Charleston, WV 25305 Name of evaluator: _________________________________________________ Make check payable to:_______________________________________________ Address for remittance:_______________________________________________ ________________________________________________ Phone:___________________ Fax: ___________________ E-mail address:_________________________________ Payee’s Social Security Number or F.E.I.N. (whichever applies):_________________________________________ Highest Education completed: “ Bachelors Degree Field : “ Psychology “ Psychiatry “ Masters Degree “ Counseling “ Doctoral Degree “ Social Work “ Law “ Other HOURLY RATE IS $45.00 FOR OUT-OF COURT AND $65.00 FOR IN-COURT, NOT EXCEEDING A TOTAL OF $750.00 HOURS SPENT ON THE CASE (MUST BE ROUNDED TO TENTHS OF AN HOUR) TASK HOURS SPENT RATE OF PAY IN-COURT 65.00 OUT-OF-COURT TOTAL 45.00 TOTALS - BILLING INFORMATION: Please pay the Parenting Plan Home Study Evaluator listed above $______________ for performing an evaluation on Case # _______________ from ________________________County Amount of payment may not exceed $750.00 per case Evaluators‘s Signature ______________________________________________________________ Date ________ * MUST be signed by parenting plan evaluator in blue ink Please attach a copy of the Judge’s Order Approving Payment and a signed Independent Contractor’s Agreement Approved by Supreme Court: _________________________________________________________ SCA–FC-502 (6/03) Date:_________________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Evaluator’s Name: ____________________________________________________________________ PARENT CONTACT INFORMATION (1) Case # __________________________ Name: __________________________________________ Address: ____________________________________ ____________________________________ Daytime Phone: ___________________________ (2) Evening Phone: ______________________ Name: __________________________________________ Address: ________________________________________ ________________________________________ Daytime Phone: ___________________________ Evening Phone: _____________________ SESSION INFORMATION: County(ies) Conducted in: ________________________________________________________________ Did either parent fail to attend the meeting? If yes which parent(s) did not attend? “ Yes “ No “ Mother “ Father “ Both Had the parties reached an agreement before the scheduled evaluation? “ Yes, full agreement “ Yes, partial agreement “ No agreements reached Whom did you interview? (Please list the name and the number of hours spent with each person) Mother: _________________________________ Number of hours _____________ Father: _________________________________ Number of hours _____________ Child(ren): _________________________________ Number of hours _____________ _________________________________ Number of hours _____________ _________________________________ Number of hours _____________ _________________________________ Number of hours _____________ Other: ________________________________ Number of hours _____________ Other: _________________________________ Number of hours _____________ Other: ________________________________ Number of hours _____________ SCA–FC-502 (6/03) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com