Statement For Payment Page 2
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1
2Case Name:
Case Number:
STATEMENT FOR PAYMENT
I represent that the foregoing is a true and reasonable bill for the services I rendered and for the costs
incurred. I certify that I have not and will not receive any other compensation for the services or costs
specified on the attached itemization.
Date
Provider Signature
I hereby certify that I have examined the above statement and find the charge of $
to be
reasonable.
Date
Presiding Judge Signature
IMPORTANT REQUIREMENTS
for filing statement with court
Attorney or Guardian ad Litem Statements must be submitted to the court within 60 days of the
disposition of the case, or within 60 days of being discharged, unless the presiding judge allows an
extension of time for filing the statement due to extenuating circumstances.
Other Service Provider Statements must be submitted to the court within 30 days of providing the
authorized service.
The following should be attached to this statement:
1.
A copy of the order of appointment or order authorizing services, if applicable.
2.
Itemization of all charges, including the date, amount of time and rate.
3.
Itemization of all expenses, including a description of each expense and the cost of
each expense.
4.
A copy of the order or notice of decision, if any, granting a motion to exceed the fee
cap related to the case.
FOR COURT USE ONLY:
CASE TYPE:
COURT CODE:
NHJB-2154-P (03/30/2010)
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