Voucher For Assigned Counsel Physician Psychiatrist Psychologist Social Worker Or Investigators {JC2020}

STATE OF NEW YORK - UNIFIED COURT SYSTEM VOUCHER FOR ASSIGNED COUNSEL, PHYSICIAN, PSYCHIATRIST, PSYCHOLOGIST, SOCIAL WORKER OR INVESTIGATORS JC 2020 Voucher ID: PLEASE SEE INSTRUCTIONS FOR MORE INFORMATION AND REQUIRED DOCUMENTION VENDOR INFORMATION 1. Vendor Name: 3. Business Name: 4. Address: City: 5. Docket/Index/File#: 2. Vendor Identification Number: State: 6. Ref/Inv#: Zip Code: County: 7. Date: 8. Type of service rendered: Legal Physician Psychiatrist Psychologist Social Worker Investigators Other 9. For services rendered by counsel, mental health professionals, physicians or investigators pursuant to section 35 of the Judiciary Law in the Supreme/ Surrogate/Family/County Court of__________________________County during the period from ______/______/______to_______/______/_______ for_________________________________________________________ Docket/Index/File number:_____________________ VENDOR CERTIFICATION 10 Total Hours Amount Dollars Cents Expenses: TOTAL FEE: 11. I hereby certify that the above statement of services provided is true and correct, and that no other claim for payment has been made for the time stated therein and that no part thereof has been paid, except as stated therein and that the balance stated is due and owing and that taxes from which the State is exempt are excluded therefrom. SIGNATURE DATE I hereby certify that in accordance with the above statement of services, the total fee awarded for such services is fair and just and is set forth above. FOR USE OF COURT JUDGE/JUSTICE SIGNATURE DATE FOR UCS ADMINISTRATIVE PURPOSES ONLY I hereby certify that this voucher is correct and just and payment is hereby approved. SIGNATURE DATE Business Unit ChartField 2 Amount Budget Date Dept. FOR UCS BUDGET PROCESSING OFFICE ONLY Program Fund Account Bud Ref Oper Unit ChartField 1 Liability Date: Merch/Inv. Rec'd Date: JC 2020 (Rev. 4/13) American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Preparing JC 2020 Vouchers for Assigned Counsel, Physician, Psychologist, Social Worker or Investigators Voucher ID: -Agency Internal Use Only 1. 2. Vendor Name: For individuals, enter the name of the vendor as it appears in SFS. Vendor Identification Number: Enter the ten digit number provided by the Office of the State Comptroller to conduct business in New York State. If payment should be made to your firm, please enter the firm's vendor ID#. (If you do not have a Vendor ID, please contact the appropriate Appellate Division). Business Name: Enter the Legal Business name as it appears in SFS. Address: Enter the physical address as it appears in SFS (For change of address, please refer to www.osc.state.ny.us/vendors/forms/add_change_change_delete.pdf) Docket/Index/File#: Enter the appropriate court docket, index or file number(s) associated with the case. Ref/Inv#: Enter last name of client for whom services were performed or invoice number. Date: Enter the date the voucher is submitted. Type of service rendered: Indicate type of service rendered as appropriate. Indicate the county, the period of service rendered, the name of the client for whom the services were performed and the appropriate court docket, index or file number(s). Amount: Enter total hours and amount in dollars and cents. Enter the expenses in dollars and cents. Enter the total fee being charged to the State (Apportionment, if applicable) in the "Total Fee" box in dollars and cents. Vendor Certification: The vendor authorized to claim fees must sign and date the Certification. 3. 4. 5. 6. 7. 8. 9. 10. 11. Attached Required Documentation: The following documentation must be submitted with the voucher for payment: a. A copy of the Court Order authorizing payment b. Affidavit in Support of voucher for compensation in excess of Statutory Maximum, if appropriate. c. Itemized billing statement including date of service, to whom the services were rendered, type of service and time spent on each date of service. JC 2020 (Rev. 5/13) FIGURE 5 American LegalNet, Inc. www.FormsWorkFlow.com