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Statement Of Service And Order For Payment Of Court Appointed Representative MC 221 - Michigan
| Statement Of Service And Order For Payment Of Court Appointed Representative Form. This is a Michigan form and can be used in General Criminal Statewide . |
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PROBATE OSM CODE: ASE Original - Court Approved, SCAO 1st copy - Attorney STATE OF MICHIGAN CASE NO. STATEMENT OF SERVICE AND JUDICIAL DISTRICT ORDER FOR PAYMENT OF JUDICIAL CIRCUIT COURT APPOINTED REPRESENTATIVE COUNTY PROBATE ORI Court address Court telephone no.MI- Defendants/Respondents name, address, and telephone no. The State of Michigan THE PEOPLE OF v CTN SID DOB Juvenile Probate In the matter of STATEMENT OF SERVICE 1. I, , was appointed by the court to serve as the Name (type or print) for , and services have been rendered. Specify attorney, lawyer-guardian ad litem, etc.Name (type or print) 2. Compensation from any other source is not being sought. 3. Dates and the nature of services rendered and expenses are as follows: DATE SERVICE/EXPENSE TIME DATE SERVICE/EXPENSE TIME I declare that the above statements are true to the best of my information, knowledge, and belief. Date Attorney/Guardian ad litem/Lawyer-Guardian ad litem signature Bar no.Social security no. Address Federal identification no. City, state, zip Telephone no.NOTE: If requesting payment for services rendered as a lawyer-guardian ad litem, you must attach Form JC 82, Affidavit of Service Performedby Lawyer-Guardian Ad Litem. ORDER FOR PAYMENT I certify that was appointed to represent the named defendant/respondent/ child(ren) and that the service was rendered. IT IS ORDERED disbursing officer shall pay $ to District control unit/County to compensate him/her for all time and expense in connection with this case. Name (type or print) Date Judge Bar no. Check no. in the amount of $ issued on . Date MC 221 (9/03) STATEMENT OF SERVICE AND ORDER FOR PAYMENT OF COURT APPOINTED REPRESENTATIVE
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