Free Statement for payment - New Hampshire

Instructions

Clear Form

THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

STATEMENT FOR PAYMENT
Attorney (ATTY) ATTY or GAL for: 1. Name of payee Address of payee Social Security 2. 3. 4. or Federal Tax Identification No. of payee Guardian Ad Litem (GAL) Respondent Father Mother Other Service Provider Child Proposed Ward

Name of Attorney, GAL or service provider if different from payee If Attorney or GAL on this case, date of appointment by court (Attach copy of the order of appointment) If Other Service Provider, date services authorized by the court Type of services authorized Amount authorized $ (Attach copy of the order authorizing service, if applicable)

5. 6.

Type of billing:

Final

Interim

Supplemental

Billing Period: This statement is for the period beginning and ending

7.

Billing Amount: (Attach itemization of all charges, including date, amount of time, rate.) SERVICE FEES Provider Paralegal Attorney GAL Other Provider Total time hours hours hours hours Rate $35/hour $60/hour $60/hour $ _____/hour $ $ $ $ $ $ $ Cost TOTAL

TOTAL SERVICE FEES EXPENSES (Attach itemization of all expenses.) TOTAL EXPENSES TOTAL OF THIS BILL 8.

Total of previous bills in this case: $ (Attach copy of order or notice of decision, if any, granting motion to exceed fee cap.)
Page 1 of 2

NHJB-2154-P (02/01/2008) (formerly AOC-409-003)

Case Name: Case Number: STATEMENT FOR PAYMENT

I represent that the foregoing is a true and reasonable bill for the services I rendered and for the costs incurred. I certify that I have not and will not receive any other compensation for the services or costs specified on the attached itemization.
Date Provider Signature

I hereby certify that I have examined the above statement and find the charge of $ reasonable.
Date Presiding Judge Signature

to be

IMPORTANT REQUIREMENTS for filing statement with court Attorney or Guardian ad Litem Statements must be submitted to the court within 60 days of the disposition of the case, or within 60 days of being discharged, unless the presiding judge allows an extension of time for filing the statement due to extenuating circumstances. Other Service Provider Statements must be submitted to the court within 30 days of providing the authorized service. The following should be attached to this statement: 1. A copy of the order of appointment or order authorizing services, if applicable. 2. Itemization of all charges, including the date, amount of time and rate. 3. Itemization of all expenses, including a description of each expense and the cost of each expense. 4. A copy of the order or notice of decision, if any, granting a motion to exceed the fee cap related to the case.

FOR COURT USE ONLY: CASE TYPE:

COURT CODE:

NHJB-2154-P (02/01/2008) (formerly AOC-409-003)

Page 2 of 2

Top of 1st Page