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Fill and Sign the Statement of Reimbursable Attorney Fees Sections 6301306 Form

Fill and Sign the Statement of Reimbursable Attorney Fees Sections 6301306 Form

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OSCA (04-17 ) PR 10 1 of 1 630.130.6, 632.415.2 RSMo IN THE __ _____ JUDICIAL CIRCUIT , ________________________ COUNTY, MISSOURI Probate Division For the Month _________ _________ of Year ___ _______ (Date File Stamp) Attorney Name and Address: Tax ID Number or Social Security Number: * Filing/Hearing Type Mental Health Alcohol & Drug (A) 96 Hr. (E) 96 Hour (B) 21 Day (F) 30 Day (C) 90 Day (G) 90 Day (D) 1 Year (H) 180 Day (I) ECT Statement of Reimbursable Attorney Fees Section s 630.130.6 and 632.415.2 RSMo Case Number Filing Date and Hearing Date Filing/Hearing T yp e * Total Hours Total To Be Reimbursed Grand Total $ I certify the above amounts charged for attorney fees pursuant to section s 630.130 and 632.415 , RSMo , are true and accurate and have not been previously paid by the state of Missouri. Attorney’s Signature (Required) Date Judge’s or Clerk’s Signature (Required) Date Mail original completed form to: Missouri Department of Mental Health, P.O. Box 687, Jeffe rson City, MO 65102

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