NOTE:
For court testimony, copy of subpoena or court order must be attached.
(PLEASE TYPE OR PRINT LEGIBLY) CHECK HERE IF NEW ADDRESS
CLAIM OF ____________________________________________________________________________________
ADDRESS ____________________________________________________________________________________
CITY, STATE _________________________________________________________________ ZIP _______________________
E-MAIL _____________________________________________________________ PHONE ___________________________
DOCUMENT ID:
DOCUMENT TOTAL
$
COMMENTS (72)
(24)
(24)
(24)
VENDOR CODE
SUPERIOR COURT OF CALIFORNIA
COUNTY OF SAN BERNARDINO
EVALUATION
SERVICES CLAIM
CASE
NUMBER
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.
12-21283-356 Rev. 1/20
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.
APPROVED/POSTED BY ___________________________________________________________________________________ DATE __________________________
COPY OF LETTER OF
APPOINTMENT OR
FILE-STAMPED
ORDER IN SUPPORT
OF SERVICES BILLED
MUST BE ATTACHED
TYPE OF EVALUATION FEE
PC 1368/1369 Competency evaluation and report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00
PC 1368/1369 Competency evaluation and report, and determination by
MD Psychiatrist if antipsychotic medication medically appropriate . . . . . . . . . . . . $1,000.00
W&I 3050/3051 Addiction evaluation and report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00
PC 288.1 Sex Offender evaluation and report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $350.00
Adelanto Detention Center stipend . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $50.00
Court Appearance/Testimony by Psychologist . . . . . . half day $350.00 . . . . . full day . $600.00
Payment is the responsibility of subpoenaing party (LRC 1460.9).
Mileage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Current Court-Approved Rate
COURT TESTIMONY ONLY
DATE OF
TESTIMONY
TIME
AM PM
TYPE OF
EVALUATION
(see above)
DATE OF
EVALUATION
DEFENDANT
AND LOCATION
*
JUDGE/
DEPARTMENT
FEE
MILES
DRIVEN
**
COURT USE
ONLY
Approving Authority
Date
Signature of Claimant Date and Place
**
Expert’s Physical Address
(if mileage claimed):
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 County Form No. 13-17711-360 for:
PC1026 NGI and EC1017 Evaluation Services
LINE 1: 939 1100 110001
LINE 2: 939 1100 110001
LINE 3: 939 1100 110001
LINE 4: 939 1100 110001
LINE 5: 939 1100 110001
LINE 6: 939 1100 110001
G/L ACCT COST/FUND CENTER Functional Area PECT FUND AMOUNTS
APPROVED / PARKED
DATE
PC 1368/1369, W&I 3050/3051, PC 288.1
*
Indicate where evaluation occurred adjacent to defendant name:
West Valley DC; Central DC; Adelanto DC; Patton SH; or other (specify)
$
$
$
$
$
$
Page _____ of _____
USE THIS CLAIM FORM FOR PC 1368/1369, W&I 3050/3051 AND PC 288.1 SERVICES ONLY
Court Appearance/Testimony by Psychiatrist . . . . . . . half day $600.00 . . . . . full day.$1,000.00
