EFTA00032652

UNITED STATES ATTORNEYS Request, Authorization, and Order for Services of Expert Witness, Litigative Consultant, or ADR Neutral Contract/Purchase Order No.: Date: Part I - Re uest for Services 1. Requesting Official (Name & Title) 2. Signature of Requesting Official 3. Point of Contact (Name and Tel.) Telephone: 4. Date of Request 5. Proparer (Name & Tel.) 6. Originating Office (Name & Address) 7. Case Name. Court 8 Ct. Docket No. 8. DJ File No./USAO No. 9. Contractor (Namo and Tel.) Telephone: 10. Contractor Mailing Address 11. Contractor TIN or SSN (Individual) 12. Contractor Specialty 13. Reason for Request (Place an "X" in the applicable Box in the Left Column) 13.a. Expert Testimony on Behalf of U.S. 13.b. Deposition Conducted by DOJ Attorney 13.c. Medical Examination of Plaintiff/Witness/Defendant in Contemplation of Testimony on Behalf of U.S. 13.d. Examination Under 18 USC 4241. Mental Competency to Stand Trial Only 13.e. Dual Purpose Psychiatric Examination (Time of Offense and Competency to Stand Trial) on the motion of: 13J. ADR Neutral Services 13.g. Litigative Consultant Services 13.h. Other (explain below): Attach the Statement of Work to this Form 14. Negotiated Contractor Rates. Estimated Expenses. and Performance Dates (Note: Expenses incurred n ust be supported by receipts) Service/Expanse Performance Dates (From-To) Hour/Day Quantity Pato Total 14.a. Examine Case - Hour $ 0.00 14.b. Prepare Testimony - Hour $ 0.00 14.c. Court Testimony - Hour $ 0.00 14.d. Deposition - Hour $ 0.00 14.e. Litigative ConsultanUNeutral - Hour $ 0.00 14.f. Per Diem (if not part of fee) Day $ 0.00 14o. Privately Owned Vehicle (NTE coach rate) Mile $ 0.00 14.h. Common Carder Transportation Via GTA 14.1. Common Carrier Transportation Reimbursed 14.J. Miscellaneous 14.k. Total Estimated Expenses I $ 0.00 15. Submit Invoices & EFT Information to: U.S. Attorney's Office. SDNY Bud. et 8 Fiscal Unit or email: 16. Payment will be made by: (Place an 'X' in the applicable Box and fill.in if not Jfv10/Finance) X I Box 15 Form USA-47 (Revised 5-2008) Page 1 of 2 EFTA00032652