Free Court - Federal

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT COURT-ASSIGNED COUNSEL VOUCHER Appeals Docket No. Person Represented (Full Name) Full Name of Attorney In The Case Of (Short Caption) Date of Assignment Mailing Address, Including Firm Name

Social Security/Employer Identification No.
' Check here if payment should be made to attorney and reported under attorney's social security number

City, State and Zip Code
' Check here if payment should be made to law firm and reported under the firm's employer identification number

CLAIMED COMPENSATION "In-Court" "Out-of-Court" "Travel" "Other" CLAIMANT'S CERTIFICATION For period to

CLAIMED EXPENSES

I hereby certify that the above claim is correct and that I have not claimed or received payment from any other source for the services rendered and claimed.

Signature of Attorney

Date APPROVED FOR PAYMENT (To Be Completed By Court Personnel Only)

In-Court Approved

Out-of-Court Approved $ $

Travel Expenses Approved $

Other Expenses Approved $

Total Amount Approved

$

Signature of Chief Judge (or designate)

Date