Form Cja 21 - Authorization And Voucher For Expert And Other Services

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CJA 21 AUTHORIZATION AND VOUCHER FOR EXPERT AND OTHER SERVICES (Rev. 04/11)
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: Z
OR
’
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 Attorney
Date
’
’
’
’
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
’
’
06
Documents Examiner
21
Jury Consultant
Financial eligibility of the person represented having been established to the Court’s satisfaction, the
’
’
authorization requested in Item 12 is hereby granted.
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
Computer Forensics
14
Pathologist/Medical Examiner
26
’
Repayment or partial repayment ordered from the person represented for this service at time of authorization.
15
Other Medical
Expert
’
’
’
16
Voice/Audio Analyst
YES
NO
CLAIM FOR SERVICES AND EXPENSES
FOR COURT USE ONLY
16.
SERVICES AND EXPENSES
MATH/TECHNICAL
ADDITIONAL
AMOUNT CLAIMED
(Attach itemization of services with dates)
ADJUSTED AMOUNT
REVIEW
a. Compensation
b. Travel Expenses (lodging, parking, meals, mileage, etc.)
c. Other Expenses
GRAND TOTALS (CLAIMED AND ADJUSTED):
$0.00
$0.00
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/Payee
Date
18. CERTIFICATION OF ATTORNEY I hereby certify that the services were rendered for this case.
Signature of Attorney
Date
APPROVED FOR PAYMENT — COURT USE ONLY
19. TOTAL COMPENSATION
20. TRAVEL EXPENSES
21. OTHER EXPENSES
22. TOTAL AMOUNT APPROVED/CERTIFIED
$0.00
’
23.
Either the cost (excluding expenses) of these services 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
$0.00
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
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