Free Dependency Representation Claim Form (JC\E-308) - California

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SACRAMENTO Sitting as the Juvenile Court
3341 Power Inn Road, Sacramento, CA 95826 DEPENDENCY REPRESENTATION CLAIM FORM

For Accounting Use Only
Claim No: Reviewed: Approved: To Auditor: #

Date: Claim Month/Year Attorney Name: Telephone No: ( ) Attorney Address: Social Security/Fed ID NO: County Vendor NO: DECLARATION PURSUANT TO WIC §317 The above-named Attorney at Law, being duly licensed to practice in the State of California, was appointed to provide representation in the matters set forth in the attachment pursuant to WIC § 317. Further, said Attorney has not presented billings on the cases in the attachment during the fiscal year of 2005-2006. Attorney is requesting payment of $__________ for number of _________ cases. Further, Attorney has a total of ____ clients in his/her workload. I declare, under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct. Executed: _________at ________________ __________________________________
DECLARANT

ORDER The Court finds that $ __________ is a reasonable sum for compensation and for necessary expenses and orders that payment be made by the Sacramento County Auditor Controller for said sum. APPROVAL I declare, under penalty of perjury, that an itemized billing maintained in the Court's Administrative Office supports the charges listed above. _________________________________
ADMINISTRATOR

_____________________
DATE

COMMENTS

J:/mo/Procedure/formsdep/DPA Claim Form.doc JC\E-308 (03.05)

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__________________________ (Attorney Name)

Dependency Representation Billing Log
Family ID Case Number Case Name Hearing Date Representing (Name) Relationship Operations Accounting

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.
Relationship Legend S: Minor O: Other M: Mother F: Father Operations Legend OK: Verified for payment NH: No Hearing RL: Relieved (date) DT: Dependency Term. (date) PT: Parental Rights Term. (date) Accounting Legend VP: Verified for payment DP: Declined for payment

For Court Use Only

J:/mo/Procedure/formsdep/DPA Claim Form.doc JC\E-308 (03.05)

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