SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
COURT APPOINTMENT FORENSIC EVALUATION
COMPENSATION CLAIM FORM AND SUPPORTING AFFIDAVIT
CR-6079 REV 8/5/14 Court Appointment Forensic Evaluation Compensation Claim Form and Supporting Affidavit
Doctor’s Name: Date of Appointment:
Defendant/Minor Full Name:
Case Number:
Type of Proceeding:
Adult PC1368/1369 Adult PC1026/1027 Adult W&I 6605
Adult EC1017* Adult PC 288.1 Juvenile Competency Report
Juvenile WIC 702.3 (d) Juvenile EC1017* Other:
*EC 1017 Report: Date report submitted to Defense Counsel:
Evaluation Interview
Date of Interview:
Duration of Interview: Pages Reviewed:
Preparation for Interview:
Testing
Amount of Testing:
No Testing 1 hour 2 hours
Types of Test(s) Administered:
Fee Calculation
Basic Evaluation and Report Fee (first two hours) $350: $
Testing (two hours maximum) @ $95/hr MD or $85/hr PhD: $
Pre-approved additional funding (Attach approved request form CR-6080) $
(If Request for additional funds not attached it will delay payment)
Testimony time in Dept. #
Testimony date(s):
@ $250/ half-day and/or $425/ full day $
Other:
$
Total Compensation 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 Evaluator’s Signature
Mailing Address:
Phone#:
FOR COURT USE ONLY
I acknowledge receipt of the report or appointment under EC 1017 and the services are rendered as requested.
Approved by: Dated:
Asst. Director/Juvenile Supervisor
