Fill and Sign the Form C 62a

Indicate if Original Charge is:LimitsCapital Case (or charge carrying sentence of life without parole)G(No Limit) CC Class A FelonyG($3,500) FA Class B FelonyG($2,500) FB Class C FelonyG($1,500) FC OtherG($1,000) OT AppealG($2,000) AP Petition for Writ of CertiorariG($2,000) WC Post-Conviction/Habeas CorpusG($1,00) PC Sworn to and subscribed before me this _______ day of ______________, ____ _________________ Notary Public State of Alabama Unified Judicial System Form C-62A Rev. 7/2000ATTORNEY’S FEE DECLARATION (Adult) [For Work Performed On or After 10/1/2000]County Code __ __Case Number _ _ _ _ _ _ _ _ __ __ __ Jurisdiction Year Case# Suffix Mark Appropriate Court:Attorney Name (Please type or print) G Circuit Court of ___________ County G District Court of ________ County_________________ G Municipal Court of ______ G Alabama Court of Criminal Appeals_________________ G Alabama Court of Civil AppealsSocial Security Number or FEIN G Supreme Court of Alabama STYLE OF CASE:G G STATE OF ALABAMA G G MUNICIPALITY OF___________v. __________________ Defendant CHARGE: ___________________________ Companion case numbers and charges or convictions: _____________ ____________________ The undersigned attorney declares that on (date) _______, the Honorable _______ ______ , Judge, appointed the undersigned to represent the above-named defendant or appellant, and on (date) _____ the case was heard by the Honorable ________________, Judge. The case was disposed of by __________________________________ (Plea of guilty, conviction, acquittal, affirmance, reversal, cert. denied) (1)In-Court Appearance (Trial Level or Post-Conviction Proceeding)Total Hours __ x$ 60.00 per hour=___________ (2)Out-of-Court Preparation (Trial Level or Post-Conviction Proceeding)Total Hours ____ x $ 40.00 per hour=__________ (3)Preparation (Appellate Level)Total Hours ____ x $ 60.00 per hour=___________ (4)Extraordinary Expenses (If approved in advance by court)___________ (5)Overhead Expenses (If approved in advance by court)Total Hours _____ x$ __ Per hour=__________ TOTAL CLAIM OF ATTORNEY___________ NOTICE TO ATTORNEY: Complete this form. Attach a copy of a complete itemization of (1) in-court appearances; (2) out-of-court preparation; (3) preparation for appeals; (4) extraordinary expenses; and/or (5) overhead expenses reflecting the date of actions and amount of time involved in each activity. Make a copy of same for the court’s record and a copy for your records. The undersigned attorney further declares that the above claim is true and correct and represents the services actually rendered by him/her as an attorney and the amount is due and payable. I further declare that the above claim is not a duplication of charges and expenses in any case (companion or otherwise). ______________________ Signature of Attorney Attorney Code _______ Mailing Address of Attorney (please type or print) (including city, state, and zip code) __________________ _________________ __________________ Telephone Number ______Fax Number _______ I, the undersigned judge, hereby certify that the foregoing claim has been presented to me, and I have reviewed the same and believe the same to be true and correct. I am further of the opinion that said attorney is not duplicating said charges and expenses in any case (companion or otherwise). Based on the above, I hereby approve the declaration and claim in the amount of $ ___________________ Done this _____ day of __________, ____.________________________ Judge’s Signature NOTICE TO ATTORNEY AND JUDGE: Sections 15-12-21 through 15-12-23, Code of Alabama 1975, provide for the payment of attorney fees and extraordinary expenses incurred by counsel appointed to represent indigent defendants at the trial level, on appeal (including petition for writ of certiorari to the Alabama Supreme Court) and in post-conviction proceedings. THIS FORM MUST CONTAIN ORIGINAL SIGNATURES OF THE ATTORNEY AND THE JUDGE. THIS FORM WITH ATTACHED ITEMIZATION MUST BE SUBMITTED TO THE TRIAL COURT JUDGE OR PRESIDING JUDGE OR CHIEF JUSTICE OF THE APPELLATE COURT FOR APPROVAL. AFTER APPROVAL, FILE WITH THE CLERK, WHO SHALL SUBMIT THE ORIGINAL DECLARATION TO THE STATE COMPTROLLER (EXCEPT IN MUNICIPAL CASES) FOR AUDIT. Filed in the Clerk’s Office at _____________, Alabama, on ________ date EXCEPT IN MUNICIPAL CASES, MAIL TO: State Comptroller, Indigent Defense Section, P. O. BOX 302602, Montgomery, Alabama 36130-2602 Original: ComptrollerYellow: Court FilePink: Attorney