7. Each month since my appointment I have sent billing statements to the parties through their attorneys of
record, or, if self-represented, to the party directly. I am submitting with this application, copies of those
statements as Exhibit “A,” not to be filed in the court file. My time was billed at the rate of $
per hour. If applicable, I have billed paralegal time at the rate of $ per hour. I have
recorded hours at no charge.
8. I am requesting fees in the amount of and costs in the amount of . I recommend that the
court allocate the payment of such fees and costs as follows:
% to be paid by Mother;
% to be paid by Father;
% to be paid by the Superior Court
for the following reason(s):
9. I mailed a copy of this Application and Exhibits with a blank Response and blank Income and Expense
Declaration to the parties or their attorneys of record on .
A copy of this Application and Exhibits with a blank Response and blank Income and Expense
Declaration was served on the parties or their attorneys of record on .
10. I am submitting this Application and Exhibits to the clerk of Department .
11. I am submitting this Application and Exhibits to the Superior Court Finance Department.
12. I request Abstracts of Judgment and Earnings Withholdings Orders be issued for the following reasons:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
NOTICE TO PARTIES:
You must complete the form “Response to Application for Payment of Fees and Costs of Children’s
Counsel” and follow the procedures set out in that form. Your response must be received within 21
calendar days of the date of this application. See “Payment Procedure for Children’s Attorney,” enclosed.
Failure to submit a response may result in an order directing you to pay up to 100% of the fees and costs
*or mailed to: Superior Court of California, County of Santa Clara
191 North First St., San José, CA 95113
FM-1067 REV 08/01/16
APPLICATION FOR PAYMENT OF ATTORNEY FEES AND
COSTS OF CHILDREN’S COUNSEL
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