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CJA 20 APPOINTMENT OF AND AUTHORITY TO PAY COURT APPOINTED COUNSEL (Rev. 5/99) 1. CIR./DIST./DIV. CODE 2. PERSON REPRESENTED 3. MAG. DKT./DEF. NUMBER 4. DIST. DKT./DEF. NUMBER 5. APPEALS DKT./DEF. NUMBER

VOUCHER NUMBER 6. OTHER DKT. NUMBER

7. IN CASE/MATTER OF (Case Name) 8. PAYMENT CATEGORY 9. TYPE PERSON REPRESENTED 10. REPRESENTATION TYPE (See Instructions) Felony Petty Offense Adult Defendant Appellant Misdemeanor Other Juvenile Defendant Appellee Appeal Other: 11. OFFENSE(S) CHARGED (Cite U.S. Code, Title & Section) If more than one offense, list (up to five) offenses charged, according to severity of offense. 12. ATTORNEY'S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS 13. COURT ORDER O Appointing Counsel F Subs For Federal Defender P Subs For Panel Attorney Prior Attorney's Name: Telephone Number: ________________________ Appointment Date:
Because the above-named person represented has testified under oath or has otherwise satisfied the Court that he or she (1) is financially unable to employ counsel and (2) does not wish to waive counsel, and becasue the interests of justice so require, the attorney whose name appears in Item 12 is appointed to represent this person in this case, OR Other (See Instructions) Signature of Presiding Judicial Officer or By Order of the Court

C Co-Counsel R Subs For Retained Attorney Y Standby Counsel

14. NAME AND MAILING ADDRESS OF LAW FIRM (Only provide per instructions)

Date of Order Nunc Pro Tunc Date Repayment or partial repayment ordered from the person represented for this service at time of appointment. Yes No

CLAIM FOR SERVICES AND EXPENSES
CATEGORIES (Attach itemization of services with dates) HOURS CLAIMED TOTAL AMOUNT CLAIMED

FOR COURT USE ONLY
MATH/TECH. MATH/TECH. ADJUSTED HOURS ADJUSTED AMOUNT ADDITIONAL REVIEW

15. a. Arraignment and/or Plea b. Bail and Detention Hearings c. Motion Hearings d. Trial e. Sentencing Hearings f. Revocation Hearings g. Appeals Court h. Other (Specify on additional sheets) (RATE PER HOUR = $ ) TOTALS: 16. a. Interviews and Conferences b. Obtaining and reviewing records c. Legal research and brief writing d. Travel time e. Investigative and other work (Specify on additional sheets) (RATE PER HOUR = $ ) TOTALS: 17. Travel Expenses (lodging, parking, meals, mileage, etc.) 18. Other Expenses (other than expert, transcripts, etc.) GRAND TOTALS (CLAIMED AND ADJUSTED): 19. CERTIFICATION OF ATTORNEY/PAYEE FOR THE PERIOD OF SERVICE 20. APPOINTMENT TERMINATION DATE IF OTHER THAN CASE COMPLETION FROM: TO: Out of Court In Court

21. CASE DISPOSITION

22. CLAIM STATUS Final Payment Interim Payment Number Supplemental Payment Have you previously applied to the court for compensation and/or reimbursement for this case? Yes No If yes, were you paid? Yes No Other than from the Court, have you, or to your knowledge has anyone else, received payment (compensation or anything of value) from any other source in connection with this representation? Yes No If yes, give details on additional sheets. I swear or affirm the truth or correctness of the above statements. Signature of Attorney 23. IN COURT COMP. Date APPROVED FOR PAYMENT - COURT USE ONLY 24. OUT OF COURT COMP. 25. TRAVEL EXPENSES 26. OTHER EXPENSES DATE 31. TRAVEL EXPENSES 32. OTHER EXPENSES DATE

27.TOT. AMT. APPR./CERT. 28a. JUDGE/MAG. JUDGE CODE 33.TOT. AMT. APPROVED 34a. JUDGE CODE

28. SIGNATURE OF THE PRESIDING JUDICIAL OFFICER 29. IN COURT COMP. 30. OUT OF COURT COMP.

34. SIGNATURE CHIEF JUDGE, COURT OF APPEALS (OR DELEGATE) Payment approved in excess of the statutory threshold amount.