Dependency Representation Claim Form printable pdf download

Dependency Representation Claim Form

For Accounting Use Only

SUPERIOR COURT OF CALIFORNIA,

Claim No:

COUNTY OF SACRAMENTO

Reviewed:

Sitting as the Juvenile Court

Approved:

3341 Power Inn Road, Sacramento, CA 95826

To Auditor:

DEPENDENCY REPRESENTATION CLAIM FORM

Date:

Claim Month/Year

Attorney Name:

Telephone No: (

)

Attorney Address:

Social Security/Fed ID NO:

County Vendor NO:

DECLARATION PURSUANT TO WIC §317

The above-named Attorney at Law, being duly licensed to practice in the State of

California, was appointed to provide representation in the matters set forth in the

attachment pursuant to WIC § 317. Further, said Attorney has not presented billings on

the cases in the attachment during the fiscal year of 2005-2006. Attorney is requesting

payment of $__________ for number of _________ cases. Further, Attorney has a total

of ____ clients in his/her workload.

I declare, under penalty of perjury, under the laws of the State of California, that the

foregoing is true and correct.

Executed: _________at ________________

__________________________________

DECLARANT

ORDER

The Court finds that $ __________ is a reasonable sum for compensation and for

necessary expenses and orders that payment be made by the Sacramento County Auditor

Controller for said sum.

APPROVAL

I declare, under penalty of perjury, that an itemized billing maintained in the Court’s

Administrative Office supports the charges listed above.

_________________________________

_____________________

ADMINISTRATOR

DATE

COMMENTS

J:/mo/Procedure/formsdep/DPA Claim Form.doc

JC\E-308 (03.05)

page______of ____ pages

Dependency Representation Claim Form

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