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Get AK ADM-122 2010-2021

Rint or Type Counselor s Name Tax I.D. Number Address Phone Number City State ZIP Billing Information Type of Session: Group Individual Number of Sessions Dates of Counseling Sessions: Hourly Rate x Total Hours $0 Total Amount Billed Date Counselor s Signature Court Use Only Recommend Approval Judge s Signature Date Administrative Officer s Signature Date Approved by For Acct. Purposes: Ledger Code 41900030 ADM-122 (9/10) BILLING FORM FOR POST-TRIAL JUROR COUNS.

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