Free CJA 21 - Authorization and Voucher for Expert and Other Services - California


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OCJA 21 AUTHORIZATION AND VOUCHER FOR EXPERT AND OTHER SERVICES (Rev. 1/06)
1. CIR./DIST./ DIV. CODE 3. MAG. DKT./DEF. NUMBER 7. IN CASE/MATTER OF (Case Name) 2. PERSON REPRESENTED 4. DIST. DKT./DEF. NUMBER 8. PAYMENT CATEGORY VOUCHER NUMBER 5. APPEALS DKT./DEF. NUMBER 9. TYPE PERSON REPRESENTED 6. OTHER DKT. NUMBER 10. REPRESENTATION TYPE (See Instructions)

G Felony G Misdemeanor G Appeal

G Petty Offense G Other

G Adult Defendant G Juvenile Defendant G Other

G Appellant G Appellee

11. OFFENSE(S) CHARGED (Cite U.S. Code, Title & Section) If more than one offense, list (up to five) major offenses charged, according to severity of offense.

REQUEST AND AUTHORIZATION FOR EXPERT SERVICES
12. ATTORNEY'S STATEMENT

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.
Signature of Attorney

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 (Note: Prior authorization should be obtained for services in excess of $500, excluding expenses) Date

ATTORNEY'S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS

G

Panel Attorney

G Retained Attorney

G Pro-Se

G Legal Organization

Telephone Number:
13. DESCRIPTION OF AND JUSTIFICATION FOR SERVICES (See Instructions) 14. TYPE OF SERVICE PROVIDER
01 02 03 04 05 06 07 08 09 10 11 13 14

15. COURT ORDER
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) AMOUNT CLAIMED
a. Compensation b. Travel Expenses (lodging, parking, meals, mileage, etc.) c. Other Expenses

FOR COURT USE ONLY
MATH/TECHNICAL ADJUSTED AMOUNT ADDITIONAL REVIEW

GRAND TOTALS (CLAIMED AND ADJUSTED):
17. PAYEE'S NAME AND MAILING ADDRESS

$0.00
TIN: Telephone Number:

$0.00

CLAIMANT'S CERTIFICATION FOR PERIOD OF SERVICE FROM CLAIM STATUS

TO

G

Final Payment

G Interim Payment Number

G Supplemental Payment

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. CERTIFICATION OF ATTORNEY I hereby certify that the services were rendered for this case.

Date

Signature of Attorney
19. TOTAL COMPENSATION 23 G 20. TRAVEL EXPENSES 21. OTHER EXPENSES

Date

APPROVED FOR PAYMENT -- COURT USE ONLY
22. TOTAL AMOUNT APPROVED/CERTIFIED

$0.00
G
Either the cost (excluding expenses) of these services does not exceed $500, or prior authorization was obtained. Prior authorization was not obtained, but in the interest of justice the Court finds that timely procurement of these necessary services could not await prior authorization, even though the cost (excluding expenses) exceeds $500.

Signature of Presiding Judge
24. TOTAL COMPENSATION 25. TRAVEL EXPENSES

Date
26. OTHER EXPENSES

Judge Code
27. TOTAL AMOUNT APPROVED

$0.00
28. PAYMENT APPROVED IN EXCESS OF THE STATUTORY THRESHOLD UNDER 18 U.S.C. 3006A(e)(3)

Signature of Chief Judge, Court of Appeals (or Delegate)

Date

Judge Code

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