Fill and Sign the Authorization and Voucher for Expert and Other Services Form

CJA 21 AUTHORIZATION AND VOUCHER FOR EXPERT AND OTHER SERVICES (Rev. 05/12) 1. CIR./DIST./ DIV. CODE 2. PERSON REPRESENTED VOUCHER NUMBER 3. MAG. DKT./DEF. NUMBER 4. DIST. DKT./DEF. NUMBER 5. APPEALS DKT./DEF. NUMBER 6. OTHER DKT. NUMBER 7. IN CASE/MATTER OF (Case Name)8. PAYMENT CATEGORY 9. TYPE PERSON REPRESENTED 10. REPRESENTATION TYPE ’Felony ’Petty Offense ’ Adult Defendant ’ Appellant (See Instructions) ’Misdemeanor ’Other ’ Juvenile Defendant ’ Appellee ’Appeal ’ Other 11. 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:ZOR’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 $800, excluding expenses) Signature of AttorneyDate ’ Panel Attorney ’Retained Attorney ’Pro-Se ’Legal Organization ATTORNEY’S NAME (First Name, M.I., Last Name, including any suffix), AND MAILING ADDRESS Telephone Number: 13. DESCRIPTION OF AND JUSTIFICATION FOR SERVICES (See Instructions) 14. TYPE OF SERVICE PROVIDER (See Instructions) 01 ’ Investigator 17 ’ Hair/Fiber Expert 02 ’ Interpreter/Translator 18 ’ Computer (Hardware/ 03 ’ Psychologist Software/Systems) 04 ’ Psychiatrist 19 ’ Paralegal Services 15. COURT ORDER 05 ’ Polygraph 20 ’ Legal Analyst/Consultant Financial eligibility of the person represented having been established to the Court’s satisfaction, the authorization requested in Item 12 is hereby granted.06 ’ Documents Examiner 21 ’ Jury Consultant 07 ’ Fingerprint Analyst 22 ’ Mitigation Specialist 08 ’ Accountant 23 ’ Duplication Services 09 ’ CALR (Westlaw/Lexis, etc.) 24 ’ Other (Specify) Signature of Presiding Judge or By Order of the Court 10 ’ Chemist/Toxicologist 11 ’ Ballistics 25 ’ Litigation Support 13 ’ Weapons/Firearms/Explosive Expert Services Date of Order Nunc Pro Tunc Date 14 ’ Pathologist/Medical Examiner 26 ’ Computer Forensics Repayment or partial repayment ordered from the person represented for this service at time of authorization. 15 ’ Other Medical Expert ’ YES ’NO16 ’ Voice/Audio Analyst CLAIM FOR SERVICES AND EXPENSES FOR COURT USE ONLY 16. SERVICES AND EXPENSES (Attach itemization of services with dates)AMOUNT CLAIMEDMATH/TECHNICAL ADJUSTED AMOUNTADDITIONAL REVIEW a. Compensation b. Travel Expenses (lodging, parking, meals, mileage, etc.) c. Other Expenses GRAND TOTALS (CLAIMED AND ADJUSTED): 17. PAYEE’S NAME AND MAILING ADDRESS TIN: Telephone Number: CLAIMANT’S CERTIFICATION FOR PERIOD OF SERVICE FROM TO CLAIM STATUS ’ Final Payment ’ Interim Payment Number ’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 Claimant/PayeeDate 18. CERTIFICATION OF ATTORNEY I hereby certify that the services were rendered for this case. Signature of AttorneyDate APPROVED FOR PAYMENT — COURT USE ONLY 19. TOTAL COMPENSATION 20. TRAVEL EXPENSES 21. OTHER EXPENSES 22. TOTAL AMOUNT APPROVED/CERTIFIED 23. ’ Either the total cost (excluding expenses) of all services combined does not exceed $800, 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 $800. Signature of Presiding Judge Date Judge Code 24. TOTAL COMPENSATION 25. TRAVEL EXPENSES 26. OTHER EXPENSES 27. TOTAL AMOUNT APPROVED 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