Pro Bono Neutrals Request for Reimbursement of Services {MOED-0024}

United States District Court for the Eastern District of Missouri Assigned Judge: Case Number: Case Title: Date Appointed: Date Referral Concluded: Neutral fee has been waived/reduced as to: plaintiff defendant third-party defendant (circle one) Name of party: Neutral222s Name: Make check payable to: Neutral Firm Firm or Business Name: Street Address: Suite Number: City: State: Zip: Phone: CLAIM FOR SERVICES Please note: Claim only the pro rata share of hours for which the Court has waived or reduced a party222s responsibility for your fee. Please attach your complete billing statement to this request. If applicable, subtract from total the reduced portion of your fee that has or will be paid by the party. Rate Per Hour ($ ) x ( ) Hours Claimed = Total (less reduced fee if applicable): $ . COMPENSATION IS LIMITED TO A TOTAL OF $1,000.00 PER REFERRAL. Amount Claimed $ I certify that the services performed, a copy of my billing statement is attached hereto, were reasonable and necessary. Also, I have not or will not charge or accept in connection with this case a fee or thing of value from any source other than a party or the Court. Neutral222s Signature Date APPROVED FOR PAYMENT - COURT USE ONLY IT IS HEREBY ORDERED that payment from the Fund be made in the amount of $ . Signature of the Presiding Judicial Officer: Date: PRO BONO NEUTRAL222S REQUEST FOR REIMBURSEMENT OF SERVICES American LegalNet, Inc. www.FormsWorkFlow.com