IN THE CIRCUIT COURT FOR SUMNER COUNTY
AT GALLATIN
_______________________________ )
Plaintiff, )
v. ) Case No. ______________________
_________________________________ )
Defendant. )
WITNESS FEE – OUT OF COUNTY
Was a Subpoena issued for your attendance as a witness?
□ YES. You are entitled to receive reimbursement. Please complete this form and file with the Clerk.
□ NO. The legal authority does not provide reimbursement for witnesses when a Subpoena was not issued for
appearance. Please do not complete this form. You may seek legal counsel for any questions.
Name: ______________________________________________________________________________
Address: ______________________________________________________________________________
______________________________________________________________________________
(City) (State) (Zip)
*Per Diem Allowances: ______ days @$30.00/day $________________
______ miles @ $0.58/mile (if travel more than 10 miles) $________________
*Reimbursement Allowances: _________ day(s) lodging @ up to $95.00/day $________________
_________ day(s) meals @ up to $55.00/meal $________________
Total Witness Fees $________________
*Allowances include each day required for travel to and from the trial.
Witness Signature:______________________________________
Date: ______________________________________
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of this Statement has been sent by U.S. Mail, postage prepaid, to the
following parties:____________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
This the __________________ day of _____________________, 20_____.
__________________________________________
Deputy Clerk
