Free CJA21.pdf - North Carolina

OCJA 21 AU THOR IZATION AN D VO UCH ER FOR
1 . C I R. /D I ST ./ D IV . C O D E 3. MAG. DKT./DEF. NUM BER 7. IN CA SE/M ATTE R O F (Case Name)

EXPER T AND OTHER SERV ICES (Rev. 5/99) VOU CHER NU MBER 5. APPEALS DKT./DEF. NUMBER 9. TYPE PERSON REPRESEN TED 6. OTHER DKT. NUM BER 10. REPRESENTATION TYPE (See Instructions)

2. PERSON REPRESENTED 4. DIST. DKT./DEF. NUM BER 8 . P A Y M E N T C A T EG O R Y

G Felony G Misdem eanor G Appeal

G Petty Offense G Other

G Adult Defendant G Juvenile Defendant G Other

G Appellant G Appellee

11. O FFEN SE(S ) CH AR GE D (C ite U.S . Co de, T itle & Se ction) If more than one offense, list (up to five) major offenses charged, according to severity of offense.

REQUEST AND AUTHORIZATION FOR EXPERT SERVICES
1 2 . A T TO R N E Y 'S S TA T EM E N T As the attorney for the person represented, who is named above, I hereby affirm tha t 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 U nited States pursuant to the Criminal Justice A ct. (Note: Prior authorization should be obtained for services in excess of $300, excluding expenses) Signature of Attorney Panel Attorney G Legal Organization G Pro-Se G Retained Attorney ATTORN EY'S NAM E (First N am e, M .I., Last N am e, inclu ding a ny su ffix), AND M AILING AD DRESS Date

G

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

15. COURT OR DER Financial eligibility of the person represented h aving been established to the Co urt's satisfaction, the authorization requested in Item 12 is hereby granted. Signature of Presiding Judicial Officer or By Order of the Co urt Date of Order Nunc Pro T unc 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 (W estlaw/Lexis, etc.) Chemist/Toxicologist Ballistics Weapon s/Firearms/Explosive Expe rt Pathologist/Medical Examiner

15 16 17 18 19 20 21 22 23 24

G Other Medical G Voice/Audio Analyst G Hair/Fiber Expert G Computer (Hardware/
Software/Systems)

G Paralegal Services G Legal Analyst/Consultant G Jury Consultant G Mitigation Specialist G Duplication Services
(See Instructions)

G Other (Specify)

CLAIM FOR SERVICES AND EXPENSES
16. SERVICES AND EXPENSES (Attach itemization of services with dates)
a. Compensation b. Travel Expenses (lodging , park ing, m eals, m ileage , etc.) c. Other Expenses

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

GRAND TOTALS (CLAIMED AND ADJUSTED):
1 7. P AY EE 'S NA M E (First N am e, M .I., Last N am e, inclu ding a ny su ffix), AND M AILING AD DRESS

TIN: Telephone
CLAIMANT'S CERTIFICATION FOR PERIOD OF SERVICE CLAIM STATUS TO

G Final Payment

G

Interim Payment Number

G

Supplemental Paym ent

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 O F ATTOR NEY I hereby certify that the services were rendered for this case.

Date

Signature of
1 9 . T O T AL C O M P EN S A TI O N 20. TRAVEL EXPENSES 21. OTHER EXPENSES

Date

APPROVED FOR PAYMENT -- COURT USE ONLY
22. TOTAL AMOUN T APPROVED /CERTIFIED 23. G Either the c ost (excluding expenses) of these services does not exceed $300, or prior authorization was obtained. G Prior authorization was not obtained, but in the interest of justice the Co urt finds that timely procurement of these neces sary services could not aw ait prior authorization, even though the co st (excluding expenses) exceeds $300.

Signature of Presiding Judicial Officer
2 4 . T O T AL C O M P EN S A TI O N 25. TRAVEL EXPENSES

Date
26. OTHER EXPENSES

Judge/Mag. Judge Code
27. TOTAL AMOUN T APPROVED

28. PAYM ENT APPR OVE D IN EX CESS O F THE STATU TORY THRESH OLD U NDE R 18 U.S.C. § 3006A(e)(3)

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

Date

Judge Code