(PLEASE TYPE OR PRINT LEGIBLY) CHECK HERE IF NEW ADDRESS
CLAIM OF _____________________________________________________________________________________
ADDRESS _____________________________________________________________________________________
CITY, STATE __________________________________________________________________ ZIP ___________________
E-MAIL _____________________________________________________________ PHONE ________________________
DOCUMENT ID:
TRANS DEPT.
PV NUMBER
PV
DOCUMENT TOTAL
$
COMMENTS (96)
(24)
(24)
(24)
(24)
VENDOR CODE
SAN BERNARDINO COUNTY
SUPERIOR COURT
LINE NO.
FUND DEPT ORGANIZATION APPR OBJECT GRC/PROJ/JOB NUMBER AMOUNT
LINE NO.
FUND DEPT ORGANIZATION APPR OBJECT GRC/PROJ/JOB NUMBER AMOUNT
LINE NO.
FUND DEPT ORGANIZATION APPR OBJECT GRC/PROJ/JOB NUMBER AMOUNT
2445
2445
2445
Page _____ of _____
EVALUATION
SERVICES CLAIM
CLAIM TOTAL $
I hereby certify under penalty of perjury that the foregoing claim for service is true and correct
(CCP 2015.5), that I have been continually licensed in the State of California as a psychologist/
psychiatrist for the time period during which the services claimed above were rendered, and that
no part of this claim has previously been presented or paid.
I certify that the above services were directed by the appropriate
authority and verified in accordance with established
procedures.
AUDITOR/CONTROLLER’S APPROVAL FOR PAYMENT: I hereby certify that I have examined the facts of the transaction herein set forth as evidenced by the information hereon and the documents
attached hereto. All verifications, certification, and checking of computations required by the County Charter and Government Codes have been complied with and this claim in the total amount shown
is hereby approved for payment.
COUNTY AUDITOR/CONTROLLER BY ________________________________________________________________________ DATE __________________________
200
200
200
COPY OF LETTER OF
APPOINTMENT OR
FILE-STAMPED
COURT ORDER IN
SUPPORT OF
SERVICES BILLED
MUST BE ATTACHED
TYPE OF EVALUATION FEE 5
PC 1026 Not Guilty by Reason of Insanity evaluation and report . . . . . . $350.005
EC 1017 Defense-requested confidential evaluation and report . . . . . . . $350.005
Adelanto Detention Center stipend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.005
Court testimony — half day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.005
Court testimony — full day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $600.005
NOTE:
For court testimony, copy of subpoena or court order must be attached.
Payment is the responsibility of subpoenaing party (LRC 1460.9).
Mileage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Court-Approved Rate
Approving Authority
Date
EC 1017 EXAM ONLY
I hereby certify that I have reviewed this billing and that these services
were performed at my request. The charges shown are recommended for
payment as reasonable and appropriate.
Signature of Claimant Date and Place
Date
Signature of Attorney
Additional claim forms and the Court’s Local Rules and Appointed Services Fee Schedule are
available on the Court’s website:
www.sb-court.org
Use Court Form No. 12-21283-356 for:
PC1368 Competency, PC288 Sex Offender and
W&I 3051 Addiction Evaluation Services
PC 1026, EC 1017
13-17711-360 Rev. 7/11
COURT TESTIMONY ONLY
TIME
AM PM
USE THIS CLAIM FORM FOR PC 1026 AND EC 1017 SERVICES ONLY
*
Indicate where evaluation occurred adjacent to defendant name:
West Valley DC; Central DC; Adelanto DC; Patton SH; or other (specify)
CASE
NUMBER
DATE OF
TESTIMONY
TYPE OF
EVALUATION
(see above)
DATE OF
EVALUATION
DEFENDANT
AND LOCATION
*
JUDGE/
DEPARTMENT
FEE
MILES
DRIVEN
**
TOTAL
FEE
**
Expert’s Physical Address
(if mileage claimed):
