Request for Compensation for Services and reimbursement of Out-of-pocket Expenses {MOED-0021}

Rev United States District Court for the Eastern District of Missouri Non-Appropriated FundREQUEST FOR COMPENSATION OF SERVICES AND REIMBURSEMENT OF OUT-OF-POCKET EXPENSESAssigned Judge:Case Number:Case Title:Name of Party Represented:Date appointed: Request for (check one): Interim Payment Final Payment Check box if previous payments have been made in this case: G Amount previously paid: $Judgment Entered? Yes No If yes, Date of Judgment:If applicable, date of order granting leave to withdraw:Has a fee award been made to you in this case? Attorney's Name: Make check payable to: Attorney Firm Firm or Business Name:Street Address:City/State/Zip:Phone:In Court: Hours ClaimedTotal Amount ClaimedConferencesHearingsTrialOther (specify on additional worksheet)(RATE PER HOUR = $)IN COURT TOTALS:Out of Court: Interviews and ConferencesDiscoveryLegal Research and Brief WritingTravel Time(RATE PER HOUR = $)OUT OF COURT TOTALS:OVERALL TOTALS:TOTAL COMPENSATION CLAIMED:$Depositions and Transcripts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ Investigative, Expert or Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ Travel Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ Service of Papers/Witness Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ Interpreter Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Photographs, Photocopies, Telephone Toll Calls, . . . . . . . . . . . . . . . . . . . . . . . $ Other (Please attach description) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .$ TOTAL EXPENSES CLAIMED:$TOTAL AMOUNT CLAIMED:$$Assigned Judge's SignatureDateAmount Approved$Chairperson Non-Appropriated FundDateAmount ApprovedClaim for ServicesPlease refer to the Instructions for Completing Request for Compensation of Services and Reimbursement of Expenses for time keeping Itemized ExpensesPlease refer to the overning the isbursement of unds for Expenses Incurred by ttorneys ppointed to epresent ndigent arties in ivil ceedings pursuant to 28 U.S.C. 1915(e) dance on allowable itemized expenses I swear to (or affirm) the truth and correctness of the above statements and that the work performed was, in my best judgment, necessary for the adequate preparation of the above-named case. Further, I swear (or affirm) that this request is made in the absence of other sources of prepayment or reimbursement and that if any attorney fees are otherwise recovered, I shall return an equivalent amount to the District Court fund. ( Note: The maximum compensation for attorney's fees for any one appointment in a civil case is $) DateAttorney's Signature F ORPAYMEN T APPROVED If the total of the reimbursement requested for out-of-pocket expenses and that already allowed exceeds $,000, the approval of a majority of the judges on the Non-Appropriated Fund Committee is required. Reimbursement in excess of $1,000 must be approved by four district judges. American LegalNet, Inc. www.FormsWorkFlow.com