CR-6080 REV 10/1/12 Court Appointment Forensic Evaluation Extraordinary Services Request for Additional Funds Prior to the Performance of Services
COURT APPOINTMENT FORENSIC EVALUATION
EXTRAORDINARY SERVICES
REQUEST FOR ADDITIONAL FUNDS PRIOR TO THE
PERFORMANCE OF SERVICES
Doctor’s Name:
Defendant/Minor Full Name:
Case Number:
Type of Proceeding : (Must Select One)
Adult PC1368/1369 Adult PC1026/1027 Adult W&I 6605
Adult EC 1017 Adult PC 288.1 Juvenile Competency Report
Juvenile EC 1017 Juvenile WIC 702.3(d) Other:
Justification for request:
Please be sure to explain how the circumstances of this evaluation are unusual.
If you performed extraordinary services prior to obtaining approval, Provide a detailed explanation as to why prior
approval could not be obtained.
Date of Interview: Pages Reviewed: Number of hours worked:
Requested Amount of Additional Payment in addition to Standard Fee Schedule amount
($85 PhD/$95 MD)
Additional Amount Requested
I hereby declare under penalty of perjury that to the best of my knowledge the foregoing information is true and
accurate in every respect.
Date Doctor’s Signature
Mailing Address:
Phone #:
NOTE: Copy of this form (CR-6080) must be attached with the compensation claim form (CR-6079)
Order of Court
Approved
Denied
Other:
Dated:
Judicial Officer of the Superior Court
FILED
DATED:________________
David H. Yamasaki
Chief Executive Officer/Clerk
Superior Court of California
County of Santa Clara
By:____________________
Deputy Clerk
click to sign
signature
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