O C JA 21 A U TH O R IZA TIO N AN D V O U C HER FO R EX PER T A N D O TH ER SER V IC ES (R ev. 1/06) 1. C IR ./D IST./ D IV . C O D E 3. M AG . D KT./D EF. N U M BER 7. IN C ASE /M ATTER O F (C ase N am e) 2. PERSO N R EPRESEN TED 4. D IST. D KT./D EF. N U M BER 8. G G G PAY M EN T C ATEG O R Y G Petty Offense Felony G Other Misdemeanor V O U C HER N U M BER 5. APPEALS D KT./D EF. N U M BER 9. TY PE PERSO N R EPRESEN TED G Adult Defendant G Appellant G Juvenile Defendant G Appellee G Other 6. O THER D KT. N U M BER 10. R EPRESEN TATIO N TY PE (See Instructions)
11. O FFEN SE(S) C HAR G ED (C ite U .S. C ode, Title & Section) If m ore than one offense, list (up to five) m ajor offenses charged, according to severity of offense.
REQUEST AND AUTHORIZATION FOR EXPERT SERVICES
12. ATTO R N EY 'S STATEM EN T As the attorney for the person represented, who is named above, I hereby affirm that the services requested are necessary for adequate representation. I hereby request: OR G Authorization to obtain the service. Estimated Compensation and Expenses: Z G Approval of services already obtained to be paid for by the United States pursuant to the Criminal Justice Act. (Note: Prior authorization should be obtained for services in excess of $500, excluding expenses) Signature of Attorney Panel Attorney G Retained Attorney G Pro-Se G Legal Organization ATTO R N EY 'S N AM E (First N am e, M .I., Last N am e, including any suffix), AN D M AILIN G AD D R ESS Date
13. D ESCR IPTIO N O F AN D JU STIFIC ATIO N FO R SERV IC ES (See Instructions) 14. TY PE O F SERV IC E PRO V ID ER 01 02 03 04 05 06 07 08 09 10 11 13 14
15. C O U R T O R D ER Financial eligibility of the person represented having been established to the Court's satisfaction, the authorization requested in Item 12 is hereby granted. Signature of Presiding Judge or By Order of the Court Date of Order Nunc Pro Tunc Date Repayment or partial repayment ordered from the person represented for this service at time of authorization. G YES G NO
G G G G G G G G G G G G G
Investigator Interpreter/Translator Psychologist Psychiatrist Polygraph Documents Examiner Fingerprint Analyst Accountant CALR (Westlaw/Lexis, etc.) Chemist/Toxicologist Ballistics Weapons/Firearms/Explosive Expert Pathologist/Medical Examiner
15 16 17 18 19 20 21 22 23 24
G G G G G G G G G G
Other Medical Voice/Audio Analyst Hair/Fiber Expert Computer (Hardware/ Software/Systems) Paralegal Services Legal Analyst/Consultant Jury Consultant Mitigation Specialist Duplication Services (See Instructions) Other (Specify)
CLAIM FOR SERVICES AND EXPENSES
16. SERVICES AND EXPENSES (Attach itemization of services with dates)
a. C ompensation b. Travel Expenses (lodging, parking, m eals, m ileage, etc.) c. O ther Expenses
FOR COURT USE ONLY
AMOUNT CLAIMED MATH/TECHNICAL ADJUSTED AMOUNT ADDITIONAL REVIEW
GRAND TOTALS (CLAIMED AND ADJUSTED):
17. PAY EE'S N AM E AN D M AILIN G AD D R ESS TIN: Telephone Number:
CLAIMANT'S CERTIFICATION FOR PERIOD OF SERVICE CLAIM STATUS G Final Payment
G Interim Payment N umber
I hereby certify that the above claim is for services rendered and is correct, and that I have not sought or received payment (compensation or anything of value) from any other source for these services.
Signature of Claimant/Payee
18. C ER TIFIC ATIO N O F ATTO R N EY I hereby certify that the services w ere rendered for this case.
Signature of Attorney
APPROVED FOR PAYMENT -- COURT USE ONLY
19. TO TAL CO M PEN SATIO N 20. TR AV EL EX PEN SES 21. O THER EX PEN SES 22. TO TAL AM O U N T APPR O V ED /C ER TIFIED 23. G Either the cost (excluding expenses) of these services does not exceed $500, or prior authorization w as obtained. G Prior authorization w as not obtained, but in the interest of justice the C ourt finds that timely procurement of these necessary services could not aw ait prior authorization, even though the cost (excluding expenses) exceeds $500.
Signature of Presiding Judge 24. TO TAL CO M PEN SATIO N 25. TR AV EL EX PEN SES
D ate 26. O THER EX PEN SES
Judge C ode 27. TO TAL AM O U N T APPR O V ED
28. PA Y M EN T A PPR O V ED IN EX C ESS O F THE STA TU TO R Y TH R ESH O LD U N D ER 18 U .S.C . § 3006A(e)(3)
Signature of C hief Judge, C ourt of Appeals (or D elegate)
Judge C ode