Statement For Payment

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Instructions
Clear Form
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
Court Name:
Case Name:
Case Number:
(if known)
STATEMENT FOR PAYMENT
Attorney (ATTY)
Guardian Ad Litem (GAL)
Other Service Provider
ATTY or GAL for:
Respondent
Father
Mother
Child
Proposed Ward
1.
Name of payee
Address of payee
Vendor number
(If unknown, leave blank and AOC Accounting will complete.)
2.
Name of Attorney, GAL or service provider if different from payee
3.
If Attorney or GAL on this case, date of appointment by court
(Attach copy of the order of appointment)
4.
If Other Service Provider, date services authorized by the court
Type of services authorized
Amount authorized $
(Attach copy of the order authorizing service, if applicable)
5.
Type of billing:
Final
Interim
Supplemental
6.
Billing Period: This statement is for the period beginning
and ending
7.
Billing Amount: (Attach itemization of all charges, including date, amount of time, rate.)
SERVICE FEES
Provider
Total time
Rate
Cost
TOTAL
Paralegal
hours
$35/hour
$
Attorney
hours
$60/hour
$
GAL
hours
$60/hour
$
Other Provider
hours
$ _____/hour
$
TOTAL SERVICE FEES
$
EXPENSES
(Attach itemization of all expenses.)
TOTAL EXPENSES
$
TOTAL OF THIS BILL
$
8.
Total of previous bills in this case: $
(Attach copy of order or notice of decision, if any, granting motion to exceed fee cap.)
NHJB-2154-P (03/30/2010)
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