Court Assigned Counsel Voucher
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1UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
COURT-ASSIGNED COUNSEL VOUCHER
Please complete your voucher in accordance with the Court’s
Assigned Counsel Payment Memorandum
and file the voucher
in paper form to the attention of Patty Layne, Clerk’s Office, 1100 East Main Street, Suite 501, Richmond, VA 23219.
Appeals Docket No.
In The Case Of (Short Caption)
Person Represented (Full Name)
Date of Assignment
Full Name of Attorney
Mailing Address, Including Firm Name
Social Security/Employer Identification No.
City, State and Zip Code
☐ Check here if payment should be made to attorney and
☐ Check here if payment should be made to law firm and
reported under attorney’s social security number
reported under the firm’s employer identification number
CLAIMED COMPENSATION
CLAIMED EXPENSES
“In-Court”
_____________________________
“Travel” ______________________________
“Out-of-Court” ____________________________
“Other” ______________________________
CLAIMANT’S CERTIFICATION
For period __________ to ____________
I hereby certify that the above claim is correct and that I have not claimed or received payment from any other source for the
services rendered and claimed.
_____________________________________
_________________________
Signature of Attorney
Date
APPROVED FOR PAYMENT
(To Be Completed By Court Personnel Only)
In-Court Approved
Out-of-Court
Travel Expenses
Other Expenses
Total Amount
Approved
Approved
Approved
Approved
$
$
$
$
$
______________________________________
__________________________
Signature of Chief Judge (or designate)
Date
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