Order Approving Payment Of Appointed Counsel Fees And Expenses Page 2
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1
2Revised July 2009
PUBLIC DEFENDER SERVICES
Defense Counsel Voucher Information Page
I.
From: _______________________________________________________________________________________________
Name of Appointed Attorney
This claim relates to proceedings in
County
Client Status:
Adult
Juvenile
Date of Appointment: __________________________
Client:
Client’s State of Residence __________
(Residence MUST be completed)
II
Type of proceeding (use letter codes). _______
A. Felony
H. Child Abuse & Neglect
B. Misdemeanor
I. Habeas Corpus (Cir. Ct.)
N. Fugitive
C. Mental Hygiene
J. Supreme Court
O. Extradition
D. Juvenile Proceedings
K. Magistrate Court Appeal
P. Other_________________________
F. Parole/Probation Revocation
L. Termination of Parental Rights
(Specify)
G. Mandamus Prohibition
M. Contempt
Q.
Municipal Charges
.
Specific Criminal
Code
Case
Disposition Date:
Charge
Citation
Number
(1)
(2)
_______________
PDS USE ONLY
(3)
Is this a Supplemental Voucher
(4)
Last date of service:
YES _____ NO _____
(5)
Date _______________________
(6)
________________
WVFIMS#____________________
III.
Fee Claimed
$_________________________
PDS USE ONLY
Actual Fee
$_______________
Expense Claimed
$_________________________
Actual Expense $_______________
Total Claimed
$_________________________
Actual Total
$_______________
I hereby affirm that the above statements are true and correct.
__________________________________________________
DATE
ATTORNEY SIGNATURE
__________________________________________
___________________________________________
Payee Telephone Number
Payee Fax Number
EMAIL ADDRESS: __________________________________________________________________________
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