Refer to 18 U.S.C. § 3006A(e)(1) and the CJA Guidelines on making Ex Parte applications for services other than counsel.
|Item 1.||CIR./DIST./DIV. CODE: This four-character location code is the circuit or district and divisional office codes of the court where the proceedings for the person represented are held.|
|Item 2.||PERSON REPRESENTED: Give the full name of the person whom you were appointed to represent.|
|Items 3-6.||DOCKET NUMBERS: Provide the case number or miscellaneous number assigned by the court. Enter the number using the last two digits of the calendar year (YY), the sequential number assigned by the court (NNNNNN), and the defendant number (DDD), as shown on the indictment or charging document. Thus, the format of the docket number is YY-NNNNNN-DDD. Note: If two or more cases are heard or tried together for the person represented, complete a separate voucher for each case in which services are provided (i.e., docket number listed). Prorate the total time among the cases. On the supporting documentation, cross reference all related claims for which costs are prorated.|
|Item 7.||IN CASE/MATTER OF (CASE NAME): In criminal cases, enter U.S. vs. Defendant's Name. If it is a multiple defendant case, give the case cite as provided on the indictment or information (e.g., U. S. vs. Lead Defendant's Name, et al). If the person represented is not a defendant (e.g., material witness), enter the first named defendant in the court's recording of the case. If this is a civil case (e.g., habeas corpus), enter the Name of the Petitioner vs. the Name of the Respondent and include the respondent's title. If other than a criminal or civil case (i.e., miscellaneous matters), enter "In the matter of" followed by the "Name of the Person Represented."|
|Item 8.||PAYMENT CATEGORY: Check the appropriate box that identifies the offense class for the representation in which the expert or other services are requested. If "Other" payment category is checked, specify the category within the scope of the CJA.|
|Item 9.||TYPE PERSON REPRESENTED: Check the box that defines the legal status of the person represented.|
|Item 10.||REPRESENTATION TYPE: From the list below, select the code that
describes the type of representation:
CC A defendant charged in a criminal case with an offense(s) that is a felony, misdemeanor, or petty offense under the U.S. Code, or an assimilated crime under a state code.FOR DEATH PENALTY CASES, USE THE CJA FORM 31 AND THE APPLICABLE TYPE OF REPRESENTATION CODE.
|Item 11.||OFFENSE(S) CHARGED: Cite the U. S. Code, title and section, or other code citation of the offense or offenses (list up to five) with which the person represented is charged. If other than a federal code is cited, state the maximum period of confinement authorized for the offense. If a civil matter, such as a habeas corpus representation or a motion attacking sentence, cite 28 U.S.C. § 2254 or 28 U.S.C. § 2255, respectively. For direct appeals from a trial disposition, cite the major offense (U.S. Code, title and section) at case disposition.|
|Item 12.||ATTORNEY'S STATEMENT, NAME AND MAILING ADDRESS: Check the appropriate
box to indicate whether the request is for authorization to obtain services,
or approval of services already provided. (Note that prior authorization
is required for compensation of all services in excess of $300.) Indicate
the estimated cost of the services requested. Note the basis for compensation
(e.g., hourly rates, daily rates, fixed fee, etc.). This statement must
be signed and dated by counsel for the person represented (or by the person
proceeding pro se). Check the appropriate box to designate attorney
status as a panel attorney, retained attorney, attorney for a legal organization
(bar association, legal aid agency, or community defender organization
not receiving a periodic sustaining grant under the CJA), or as a person
who qualifies for representation under the CJA but has chosen to proceed
Give the complete legal name of the attorney appointed to represent the person whose name is shown in Item 2. Provide the mailing address and telephone number of the attorney.
|Item 13.||DESCRIPTION OF AND JUSTIFICATION FOR SERVICES: Briefly, describe
the nature of the services requested and the reason services are necessary
to provide adequate representation.
Procedures for Requesting Psychiatric and Psychological Services.
If this is a request for an examination by a psychiatrist or psychologist, state specifically the purpose of the examination. If the examination is ordered pursuant to a statute, cite the statute (U.S. Code, title and section).
The payment procedures for psychiatric and psychological examinations are outlined below. For further information, refer to paragraph 3.11 of the CJA Guidelines.
1. If this is a court-ordered examination to determine, exclusively, the mental condition as set forth in 18 U.S.C. §§ 4241-4246, DO NOT USE THIS FORM, regardless of who requested the examination. Examinations conducted pursuant to these statutes are considered "non-defense" purpose examinations. The costs are paid by the Department of Justice, and claims for these examinations should be submitted to the U.S. Attorney.
2. If this is an examination exclusively for a "defense" purpose (where the person represented selects the expert and controls disclosure of the report), USE THIS FORM. The court order executed in Item 15 is sufficient for this purpose.
3. If this is a dual purpose examination for a "non-defense" and a "defense" purpose, USE THIS FORM. For the convenience of the expert, the Administrative Office will pay the expert the total amount approved and obtain reimbursement from the Department of Justice for one-half of the total amount approved. In order for the Administrative Office to obtain this reimbursement, a separate court order authorizing the examination must be attached to the voucher when it is submitted for payment. This order should indicate (1) who requested the examination, (2) the specific purpose(s) of the examination, (3) to whom the report of the examination is directed, and (4) to whom copies of the report are to be given. This separate order is in addition to the court order at Item 15, which also must be signed and dated by the presiding judicial officer.
4. If this is a dual purpose examination for two "non-defense" purposes (e.g., evaluation of competency to stand trial under 18 U.S.C. § 4241 and evaluation of sanity at the time of the offense under 18 U.S.C. § 4242), DO NOT USE THIS FORM. Submit the entire claim to the U. S. Attorney for payment.
Item 14. TYPE OF SERVICE PROVIDER: Check the box which identifies the type of service provider requested. If you check the box "Other," be sure to specify the type of service or service provider. If computer assisted legal research (CALR) is checked, refer to paragraph 3.15 of the CJA Guidelines for an explanation of the criteria and procedures for approval of CALR as a necessary service under the CJA.
|Item 15.||COURT ORDER: This court order must be signed and dated by the presiding judicial officer. An additional court order is not necessary except for certain psychiatric and psychological examinations as explained in the instructions for Item 13, or to authorize payment for services exceeding $300 when prior authorization was not obtained (see Item 23). Indicate whether full or partial repayment of the cost for these services was ordered by the court from the person represented by checking "Yes" or "No."|
|Item 16.||CLAIM FOR SERVICES AND EXPENSES:
COMPENSATION (16a): Enter the total amount claimed for professional services rendered. On an attachment to the voucher, describe in detail the services provided, including dates of service and the amount of time spent (in hours and tenths of hours). State the basis for the fee claimed (e.g., hourly rate, daily rate, fixed fee).
TRAVEL EXPENSES (16b): Travel related expenses that are incidental to the representation (e.g., transportation, lodging, meals, car rental, parking, bridge, road and tunnel tolls, etc.) must be itemized on a separate sheet, indicating dates the expense was incurred. Attach supporting documentation (receipts, canceled checks, etc.) for all travel expenses. Travel expenses by privately owned automobile, motorcycle, or aircraft should be claimed at the rate in effect for federal employees at the time of travel. For overnight travel, reasonable expenses for lodging and meals will be reimbursed on an actual expense basis; per diem is not allowed. Service providers are limited dto the travel and subsistence expenses of federal employees. The clerk of court can advise you of applicable rates and federal government travel regulations.
OTHER EXPENSES (Item 16c): Itemize all reimbursable out-of-pocket expenses incidental to the services provided. Provide dates and a brief description of the expense. Submit supporting documentation (receipts, canceled checks, paid invoice, etc.) for single item expenses of $50 or more. Do not include general office overhead (e.g., rent, telephone services, secretarial services) as reimbursable expenses.
The columns provided "FOR COURT USE ONLY" will reflect any mathematical or technical adjustments to the claim during judicial approval or required additional review of the chief judge of the court of appeals (or delegate).
|Item 17.||PAYEE'S NAME AND MAILING ADDRESS, TAXPAYER IDENTIFICATION NUMBER (TIN), CLAIMANT'S CERTIFICATION AND CLAIM STATUS: Provide the complete name and address of the payee (claimant). The claimant must certify dates covered in the claim for payment by indicating the date range for services rendered. Check the box to indicate the status of the claim as: (1) final payment for the services, (2) an interim payment, or (3) a supplemental payment (an additional claim submitted after a the final payment). If this is an interim payment, indicate the interim payment number. The claimant or payee must sign and date the payment certification statement prior to submitting the claim to the attorney for certification that services were rendered and received. Provide the Taxpayer Identification Number (TIN) to report these earnings to the IRS.|
|Item 18.||CERTIFICATION OF ATTORNEY: This section must be completed by the attorney appointed to provide representation, a retained attorney whose client is unable to afford the cost of service requested, or by a person proceeding pro se under the CJA.|
|Items 19-22.||APPROVED FOR PAYMENT: The court will review, for reasonableness
and compliance with the CJA Guidelines, every claim for compensation
of services rendered and any claim for reimbursement of expenses incurred.
The presiding judicial officer will indicate the amount approved for payment
in each of the payment categories (Items 19-21). These amounts will reflect
any mathematical or technical adjustments made to the claim.
The "TOTAL AMOUNT APPROVED/CERTIFIED" (Item 22) is the amount approved for payment of the claim, less any amounts to be withheld in accordance with an interim payment order. Upon preliminary approval of a claim for more than the $1,000 statutory threshold, not including expenses, the presiding judicial officer will (1) signify approval by circling the word "cert" (for word certified) and indicate the amount approved in Item 22, and (2) forward the claim to the chief judge of the court of appeals (or delegate) for additional review and approval of the excess amount.
|Item 23.||SIGNATURE OF THE PRESIDING JUDICIAL OFFICER: The presiding judicial
officer must check the appropriate box to indicate (1) either the cost,
excluding expenses, does not exceed $300, or prior authorization was obtained,
or (2) approval of cost, excluding expenses, exceeding $300 when prior
authorization was not obtained but in the interest of justice the court
finds that timely procurement of these services could not await prior authorization.
The presiding judicial officer must sign and date Item 23, indicating approval/certification
of the amount indicated in Item 22. The court will provide the judge code.
If the amount approved for compensation, excluding expenses, is less
than or equal to the $1,000 statutory limitation, the claim will be forwarded
for payment processing.
|Items 24-27.||APPROVED FOR PAYMENT: If the chief judge (or delegate) approves the excess compensation, the judge will indicate the amounts approved in each of the payment categories, Items 24-26, and the total amount approved for payment in Item 27.|
|Item 28.||SIGNATURE OF CHIEF JUDGE, COURT OF APPEALS (OR DELEGATE): Before a claim is paid for the excess amount certified, the chief judge of the appeals court (or delegate) must sign and date Item 28, approving payment for compensation that exceeds the statutory threshold. If approval is not granted, compensation will be limited to the statutory maximum for the representation and expenses approved. The JUDGE CODE will be provided by court staff.|