COURT APPOINTED ATTORNEY INVOICE

DATE:

INVOICE NO. _________

TO: Public Defender Contract Administrator
200 West Washington, 9th Floor
Phoenix, AZ 85003

Attn: Jeri Wickersham

PAYEE/FROM:

ADDRESS:

MONTH:

AMOUNT: $___________________ (call 534-2380 if you do not know amount)

TAX NUMBER (or):

SOCIAL SECURITY NUMBER:

Please remit to __________________, as payee, at the address set out above, the amount of $____________, for legal services rendered as a court appointed attorney in Phoenix Municipal Court.

                                      __________________________
Signature