Authorization-Certification For Reimbursement

UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF ILLINOIS AUTHORIZATION/CERTIFICATION FOR REIMBURSEMENT VOUCHER NUMBER DCF- Please type or print with ballpoint pe. n Case Title Case Number Presiding Judge/Magistrate Firm or Business Name Business Phone Street Address Room No. City State Zip Name of Party Represented ITEMIZED EXPENSES Depositions and Transcripts $_____________________ Investigative, Expert or Other Services $_____________________ Travel Expenses $_____________________ Witness Fees $_____________________ Interpreter Services $_____________________ Photographs, Photocopies, Telephone Toll Calls, Telegrams $_____________________Other (Please attach description) $_____________________ TOTAL AMOUNT CLAIMED $_____________________ I swear (or affirm) the truth and correctness of the above statements and that each of the listed expenses were, in my best judgment, necessaryfor the adequate preparation and pres entation of the above-named case. Ihereby request reimbursement for the total amount of expenses incurred in the preparation of this case. Attorneys Signature_______________________________ Date_____________________ Approved/ Approved/ Certified ______________________________________ Date_________ Certified $ __________ for payment Signature of Presiding Judge/Magistrate Judge FOR OFFICE USE ONLY Amount Remitted: $ Check Number Financial Officers Signature Date American LegalNet, Inc. www.USCourtForms.com