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CJA 21 AUTHORIZATION AND VOUCHER FOR EXPERT AND OTHER SERVICES (Rev. 5/99) 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 Petty Offense Felony Misdemeanor Other Appeal VOUCHER NUMBER 5. APPEALS DKT./DEF. NUMBER 9. TYPE PERSON REPRESENTED Adult Defendant Appellant Juvenile Defendant Appellee Other

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6. OTHER DKT. NUMBER 10. REPRESENTATION TYPE (See Instructions)

I 1. 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 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: Authorization to obtain the service. Estimated Compensation and Expenses: $ OR 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 $300, excluding expenses.) Signature of Attorney Panel Attorney Pro-Se Retained Attorney ATTORNEYS NAME (First Name, M.I., Last Name, including any, suffix). AND MAILING ADDRESS Legal Organization Date

Telephone Number: 13. DESCRIPTION OF AND JUSTIFICATION FOR SERVICES (See Instructions) 14. TYPE OF SERVICE PROVIDER Investigator 01 02 Interpreter/Translator 03 Psychologist Psychiatrist 04 Polygraph 05 06 Documents Examiner 07 Fingerprint Analyst 08 Accountant 09 CALR (Westlaw/Lexis, etc.) Chemist/Toxicologist 10 11 Ballistics Weapons/Firearms/Explosive Expert 13 Pathologist/Medical Examiner 14

15 16 17 18 19 20 21 22 23 24

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 Judicial Officer 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. YE S N0

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)

FOR COURT USE ONLY
AMOUNT CLAIMED MATH/TECHNICAL ADJUSTED AMOUNT ADDITIONAL REVIEW

a. Compensation b. Travel Expenses (lodging, parking, meals, mileage, etc.) c. Other Expenses

GRAND TOTALS (CLAIMED AND ADJUSTED):
17. PAYEE'S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS TIN: Telephone CLAIMANT'S CERTIFICATION FOR PERIOD OF SERVICE CLAIM STATUS Final Payment
Interim Payment Number

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

Date

Signature of

Date

APPROVED FOR PAYMENT - COURT USE ONLY
19. TOTAL COMPENSATION
23.

20. TRAVEL EXPENSES

21. OTHER EXPENSES

22. TOTAL AMOUNT APPROVED/CERTIFIED

Either the cost (excluding expenses) of these services does not exceed $300, 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 $300. Signature of Presiding Judicial Officer 25. TRAVEL EXPENSES Date 26. OTHER EXPENSES Judge/Mag. Judge Code 27. TOTAL AMOUNT APPROVED

24. TOTAL COMPENSATION

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