Free mc221.pmd - Michigan

Approved, SCAO

PROBATE JIS CODE: ASE Original - Court 1st copy - Attorney JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE

STATE OF MICHIGAN

STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT-APPOINTED REPRESENTATIVE

CASE NO.

ORI

Court address

Court telephone no.

MI-

The State of Michigan THE PEOPLE OF v

Defendant/Respondent name, address, and telephone no.

CTN

SID

DOB

Juvenile Probate

In the matter of STATEMENT OF SERVICE

1. I,
Name (type or print)

, was appointed by the court to serve as the for , and services have been rendered.

Specify attorney, lawyer-guardian ad litem, etc.

Name (type or print)

2. Compensation from any other source is not being sought. 3. Dates and the nature of services rendered and expenses are as follows: DATE SERVICE/EXPENSE TIME DATE SERVICE/EXPENSE TIME

Date Federal identification no.

Attorney/Guardian ad litem/Lawyer-Guardian ad litem signature Address

Bar no.

City, state, zip Telephone no. NOTE: If requesting payment for services rendered as a lawyer-guardian ad litem, you must attach Form JC 82, Affidavit of Service Performed by Lawyer-Guardian Ad Litem.

ORDER FOR PAYMENT

I certify that child(ren) and that the service was rendered. IT IS ORDERED
District control unit/County

was appointed to represent the named defendant/respondent/

disbursing officer shall pay $

to

to compensate him/her for all time and expense in connection with this case.
Name (type or print) Date Judge Bar no.

Check no.
MC 221 (3/09)

in the amount of $

issued on
Date

.

STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT-APPOINTED REPRESENTATIVE