Fill and Sign the Number of Payee Form

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH Court Name: Case Name: Case Number: STATEMENT FOR SERVICES OTHER THAN COUNSEL NAME AND ADDRESS OF PAYEE: Social Security or Federal I.D. Number of Payee (Check which number is provided) On , the Court authorized the provision of services other than Date counsel in the above captioned matter. The authorized service has been provided and I request compensation in the following amount of $ . TYPE OF BILLING SERVICE Date Non-Counsel Activity Total Hours Subtotal $ EXPENSES Date Description of Expense Amount Subtotal $ TOTAL $ The foregoing is a true and accurate bill for serv ices rendered. I certify that I have not and will not receive any other compensation for the services specified above. (Month, Day, Year) Signature of Service Provider I, , authorize payment of $ for services Signature of Trial Judge rendered in the above entitled matter. Date NOTE: Statements must be submitted to the tr ial court within 30 days of providing the authorized service. NHJB-2262-DFS (12/15/2006) Page 1 of 2 Case Name: Case Number: MOTION FOR SERVICES OTHER THAN COUNSEL INSTRUCTIONS   STATEMENT A separate statement must be submitted for each case in which services are provided. The statement form must be completed in full. Additional sheets may be attached to further describe services provided. Incomp lete forms will be returned. TIME FOR SUBMITTAL The Statement for Services Other Than Counsel form must be submitted to the court in which the case was heard within 30 days of the provision of the service. SERVICE The service provided must be described in sufficient detail to establish the basis for the charge. EXPENSES Expenses for mileage at the prevailing federal rate and telephone costs will be paid. All other expenses must be documented by attaching receipts to the statement. Overhead expenses for office costs will not be paid. MAXIMUM AUTHORIZATION The compensation to be paid to any person or association for services shall not exceed $300 unless the Court determines, prior to the provision of such services, that the nature or quantity of such services reasonably merits greater compensation. The limit of compensation shall not include or apply to reimbursement for expenses reasonably incurred. NHJB-2262-DFS (12/15/2006) Page 2 of 2