Statement Of Payment (Pursuant To SJC Rule 1-07} {CJP 128}

S.J.C RULE 1:07 STATEMENT OF PAYMENT Matter/Estate of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Print Form Clear Form Division Last Name In the matter of my appointment as by Justice on (date) . I hereby certify that I have performed services, the value of which is: and have incurred the following itemized expenses: $ , the value of which is: TOTAL Please check appropriate box: 1. 2. 3. 4. Commonwealth Payment Private Payment Payment to Myself (See below -Judicial Approval Required) $ $ Attach Certificate of Services and Itemization of Services pursuant to Fiscal Year 1997 Memo #14 Committee for Public Counsel Payment I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief. SIGNED UNDER THE PENALTIES OF PERJURY Signature (Print name) (Address) (Apt, Unit, No. etc.) (State) (Zip) (City/Town) Primary Phone #: B.B.O. # Approved: (Approval required only if Box 4 above is checked) Date Denied Justice NOTICE TO APPOINTEE In accordance with the General Rules of the Supreme Judicial Court, Rule 1:07 §7: "No payment shall be made or received on account of any appointment required to be recorded in the appointment docket until a statement under the penalties of perjury, certifying the services provided, amount of payment, and itemization of expenses,is filed with the clerk, register, or recorder, to be place with the papers in the case. No person holding an appointment required to be recorded in the appointment docket under §5 of this rule shall make any payments to himself or herself until such payment is approved by the court." (Emphasis supplied) CJP 128 (7/31/17) American LegalNet, Inc. www.FormsWorkFlow.com