STATE OF WISCONSIN, CIRCUIT COURT, WASHINGTON COUNTY, PROBATE/JUVENILE IN THE INTEREST OF AFFIDAVIT AND ORDER FOR PAYMENT OF FEES DOB: Case No: AFFIDAVIT STATE OF WISCONSIN WASHINGTON COUNTY ) ) ss ) The undersigned, being duly sworn states that he/she accepted appointment: as Guardian ad Litem for as adversary counsel for I did not accept appointment at the rate set in Sec. 977.08(4m), but did accept appointment at the rate set in SCR 81.02. Attached hereto is an itemized statement of the time spent on the above matter for which payment is requested. Subscribed and sworn to before me this _____ day of _________________, 20____. Notary Public, State of Wisconsin My Commission Expires: Name of Attorney _______ _______ ORDER Proof having been made to the Court that time was spent as itemized in the statement(s) attached hereto and that said fees are found to be reasonable, as follows for: IT IS ORDERED, that the Clerk of this Court shall make payment to $ fees for serving as Guardian ad Litem in the above matter, $ fees for serving as adversary counsel in the above matter, If the ward has sufficient assets, the guardian shall reimburse the County for the fees paid. If the ward has insufficient assets, such reimbursement shall be made from the ward’s social security, veteran’s benefits, pension or any other income prior to the determination of medical assistance. The Petitioner in this action must reimburse Washington County for any Guardian ad Litem fees paid, which are in excess of the amount deposited at the time of filing the Petition. The Subject of this action must reimburse Washington County for any fees paid. The parties to this action may be required to reimburse Washington County for any fees paid. BY THE COURT: Name Typed Date GF-3004 (Local) Washington County – Affidavit and Order for Payment of Fees Form (Rev. 4/11/05) American LegalNet, Inc. www.USCourtForms.com