JV-068 (Rev. 07/06/2015)
GUARDIAN AD LITEM'S
CERTIFICATE OF SERVICES Page 1
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
CASE NAME
VENDOR CODE NUMBER
DIVISION
NAME & ADDRESS OF GUARDIAN AD LITEM NAME OF APPOINTING JUSTICE
CERTIFICATION OF GUARDIAN AD LITEM
I certify under the pains and penalties of perjury:
that I have performed the services described in the attached Guardian Ad Litem Itemization of
Services, that the services and time were necessary and were within the scope of the services for
which I have been appointed, and that, where applicable, I have filed the original report with the Court
as required.
I further certify that I have have not previously billed for services provided within the scope
of this appointment.
If applicable, please complete. No. of Hours billed:
Amount billed: $
SIGNATURE OF GUARDIAN AD LITEMDATE
CERTIFICATION OF JUSTICE
I have reviewed and approve as appropriate the above named Guardian Ad Litem's attached
itemization of services for payment.
DATE SIGNATURE OF JUSTICE
TELEPHONE NUMBER:
JV-068 (Rev. 07/06/2015)
GUARDIAN AD LITEM'S
ITEMIZATION OF SERVICES Page of
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
CASE NAME
VENDOR CODE NUMBER
DIVISION
ITEMIZATION OF SERVICES
(shall not include travel, court waiting time nor time for preparation of this form)
DATE OF
SERVICE
START TIME/
END TIME
TIME SPENT
(In Minutes)
DESCRIPTION OF WORK
(Please Specify)
Total Minutes:
DATE SIGNATURE OF GUARDIAN AD LITEM
Total Minutes Divided by 60 = Hours
X $50.00 per hour = Total Amount: $
ATTACH THE FOLLOWING: A COPY OF APPOINTMENT AND A COPY OF ANY APPROVED MOTION(S). FAILURE TO PROVIDE THE
REQUIRED ATTACHMENTS WILL DELAY PROCESSING OF THIS FORM FOR PAYMENT.
PRINT NAME
2
JV-068 (Rev. 07/06/2015)
GUARDIAN AD LITEM'S
ITEMIZATION OF SERVICES Page of
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
CASE NAME
VENDOR CODE NUMBER
DIVISION
ITEMIZATION OF SERVICES
(shall not include travel, court waiting time nor time for preparation of this form)
DATE OF
SERVICE
START TIME/
END TIME
TIME SPENT
(In Minutes)
DESCRIPTION OF WORK
(Please Specify)
Total Minutes:
DATE SIGNATURE OF GUARDIAN AD LITEM
Total Minutes Divided by 60 = Hours
X $50.00 per hour = Total Amount: $
ATTACH THE FOLLOWING: A COPY OF APPOINTMENT AND A COPY OF ANY APPROVED MOTION(S). FAILURE TO PROVIDE THE
REQUIRED ATTACHMENTS WILL DELAY PROCESSING OF THIS FORM FOR PAYMENT.
PRINT NAME
3
JV-068 (Rev. 07/06/2015)
GUARDIAN AD LITEM'S
ITEMIZATION OF SERVICES Page of
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
CASE NAME
VENDOR CODE NUMBER
DIVISION
ITEMIZATION OF SERVICES
(shall not include travel, court waiting time nor time for preparation of this form)
DATE OF
SERVICE
START TIME/
END TIME
TIME SPENT
(In Minutes)
DESCRIPTION OF WORK
(Please Specify)
Total Minutes:
DATE SIGNATURE OF GUARDIAN AD LITEM
Total Minutes Divided by 60 = Hours
X $50.00 per hour = Total Amount: $
ATTACH THE FOLLOWING: A COPY OF APPOINTMENT AND A COPY OF ANY APPROVED MOTION(S). FAILURE TO PROVIDE THE
REQUIRED ATTACHMENTS WILL DELAY PROCESSING OF THIS FORM FOR PAYMENT.
PRINT NAME
4
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