Involuntary Commitment (Attorney Fee) {FRMS-MC1}

State of Alabama Unified Judicial System Form FRMS-MC1 Rev.9/2011 ATTORNEY'S FEE DECLARATION Involuntary Commitments County Code __ __ Case Number __ ____ _____ __ Year Case# Suffix Jurisdiction Mark Appropriate Court: ___Probate Court ___Circuit Court ___Alabama Court of Civil Appeals Attorney Name (Please type or print): ______________________________________________ All Limits: $1500 ______________________________________________ Social Security Number or FEIN ___Commitment ___Recommitment ___Appeal In the matter of ___________________________________________ Respondent/Patient Name The undersigned attorney, licensed to practice law in the State of Alabama, declares that on (date) ____________________________, the Honorable ________________________________________, Probate Judge, appointed the undersigned to serve as Advocate for the Petitioner, or Guardian Litem, and the case was disposed of by _________________________________________, on ___________________ (date). (1) In Court Legal Services (2) Out-of-Court Legal Services (3) Appellate Level Legal Services (4) Expert Expenses (If approved in advance by the court) (5) Reimbursable Non-overhead Expenses (Receipts attached) (Must be approved in advance if in excess of $300) Total Hours __________ x $ 70.00 per hour = $__________________ Total Hours __________ x $ 70.00 per hour = $__________________ Total Hours __________ x $ 70.00 per hour = $__________________ = $__________________ =$__________________ TOTAL CLAIM OF ATTORNEY $_____________________ NOTICE TO ATTORNEY: Complete this form. Attach a copy of a complete itemization of (1) in-court legal services; (2) out-of-court legal services; (3) appellate level legal services; (4) expert expenses; and/or (5) reimbursable non-overhead expenses reflecting the date of actions and amount of time involved in each activity. Attach original invoice or receipt for all expenses and corresponding court orders. Make a copy of same for the court's record and a copy or your records. This form and attachments must be received by the State Comptroller's Office, Fiscal Management through the Probate Court no later than 90 days from final disposition of the case. I, the undersigned attorney, declare that the above claim is true and correct and represents indigent legal services actually rendered as an attorney and that the amount is due and payable. I further declare that the above claim is not a duplication of charges and expenses in any case (companion or otherwise). ________________________________________________________ Signature of Attorney Attorney Code ____________________________________________ ________________________________________________ Date E-mail Address:_____________________________________ Mailing Address of Attorney (please type or print) (including city, state, and zip code) _________________________________________________________________ Telephone Number:__________________________________ Fax Number: ________________________________________ _________________________________________________________________ I, the undersigned probate judge/judge, hereby certify that the attorney presenting this claim provided representation in this matter, that said matter has been concluded, and that to the best of my knowledge, the bill is reasonable based on the defense provided and the appointment date listed above is correct as stated. ________________________________________ Probate Judge's Signature ________________________________________ Judge's Signature (Appeals Court other than Probate) __________________________________________________ Date NOTICE TO ATTORNEY AND JUDGE: Ala. Code (1975) §§22-52-14 et seq. provide for the payment of attorney fees and expenses incurred by counsel appointed to represent indigent defendants in probate court proceedings. THIS FORM MUST CONTAIN ORIGINAL SIGNATURES OF THE ATTORNEY AND THE JUDGE. THIS FORM WITH ATTACHED ITEMIZATION MUST BE SUBMITTED TO THE PROBATE JUDGE FOR CERTIFICATION, FILED WITH THE CLERK, AND THEN SUBMITTED TO THE STATE COMPTROLLER'S OFFICE, FISCAL MANAGEMENT. Filed in the Clerk's Office at ____________________________________________________, Alabama, on __________________________. date PROBATE COURT MAIL FORM ATTACHED TO PROBATE JUDGE DECLARATION SHEET TO: State Comptroller's Office, Fiscal Management, 100 N Union St, Suite 216, Montgomery, Al 36130. American LegalNet, Inc. www.FormsWorkFlow.com