Free 03-70 Payment Voucher and Instructions - Pennsylvania

1. APPOINTMENT LETTER INVOICE NO.

Municipal Court Attorney Payment Voucher
2. ATTORNEY NAME (Last, First, Middle Initial)) 3. ATTORNEY ADDRESS

First Judicial District of Pennsylvania Modified Guaranteed Fee System

APPOINTMENT DATE

-

-

4. ATTORNEY STATE I.D. NO.

Philadelphia, Pennsylvania 191 Attorney Telephone Number: (215)
6. DOCKET NO.

Check if this is a change of address

5. POLICE PHOTO NO.

M.C.
7. DEFENDANT NAME (Last, First, Middle Initial)

FEE SYSTEM TRAINING COMPLETED (COUNSEL FEE UNIT USE ONLY)

Must be submitted for processing and approval within 30 days of disposition/sentencing.

-

-

(Date) Felony Preliminary Hearing Disposition $200.00 VOP $150.00 Private Counsel $200.00
9. Other Provisions

8. CASE TYPE, DISPOSITION LEVEL, AND CORRESPONDING PREPARATION FEES (Check box for case type and level of proceedings at completion of counsel's service)

Misdemeanor Trial ($350 per case) Summary Offenses $150.00 5th Amendment Witness $150.00

Treatment Court $350.00 Felony Remand $350.00 Bench Warrant $150.00

Counsel removed for fault (failure to appear, etc.) will be deemed not to have earned payment. The undersigned attorney maintains their principal office in Philadelphia County, has been certified by the Bar Association Screening Committee, has completed fee system training, and understands that false statements and/or representations made herein are subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities.

10. ATTORNEY SIGNATURE

11. DISPOSITION DATE

REVIEW/ORDER FOR PAYMENT JUDGE'S SIGNATURE

DATE

Judicial Review indicates that Budget & Fiscal Office is to process immediately Budget & Fiscal Office to investigate
03-70 (Rev. 06/09)

PRESIDENT JUDGE'S SIGNATURE (When necessary for payment above the standard fee)

DATE

See reverse for instructions

Instructions for the Completion of the Municipal Court Modified Guaranteed Fee System
· Payment voucher forms are available at: Office of Criminal Listings, 206 Criminal Justice Center

General Notes

· Counsel should initiate completion of the payment voucher upon receipt of the appointment and regularly update the voucher during the course of the representation. · Please write legibly to speed processing of payment. · Please be sure to attach all necessary documents. · Please carefully complete all required sections as indicated. Instructions are detailed below. · Complete Questions 1 through 11

Instructions
(Please complete only numbers 1 through 11)
Line 1: Line 2: Line 3: Line 4: Line 5: Line 6: Line 7: Line 8: Line 9: Enter Appointment Letter invoice number and date as they appear on the appointment letter. Enter attorney's name as it appears on the appointment letter. Enter attorney's full address as it appears on the appointment letter. Enter attorney's five-digit identification number. Enter defendant's six-digit police photo number. Enter the correct docket number in the following sequence: MC-51-CR-(XXXXXXX) - Year (XXXX) Enter defendant's name as it appears on the appointment letter. Check appropriate box. Accurate completion of this section is important. It will determine the rate at which the fee is paid. Read carefully.

Line 10: Sign Payment Voucher. Failure to sign voucher will delay processing of payment. Attorney's signature represents the following averments: · The attorney was appointed by the Court to represent the defendant in this case; · The facts set forth in the payment voucher are true and correct to the best of the attorney's knowledge, information and belief; · The attorney understands that false statements herein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities; · The attorney actively and diligently represented the defendant in this case; · The payment voucher submitted is fair and reasonable compensation for services in this case based upon the time and effort expended; and · The attorney has not received, nor contracted to receive, directly or indirectly, any compensation for such services from any source other than provided in the Act of Assembly. Line 11: Enter the date the representation was concluded. The voucher form will then be handed back to the attorney who will take it or mail it with a copy of appointment letter to: Budget and Fiscal Department Counsel Fee Unit Room 395 City Hall Philadelphia, PA 19107

03-70 (Reverse)