United States District Court District of New Hampshire
CJA ATTORNEY PAYEE REGISTRATION
Name: Social Security #: Telephone: ______________________
INDICATE BELOW HOW PAYMENTS SHOULD BE REPORTED TO THE IRS
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Under my social security number and name, as indicated above OR
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To the law firm with which I am affiliated. The law firm's taxpayer identification number, name, and address are: Taxpayer ID #: Law Firm Name: Address: _________________________________________ _________________________________________ _________________________________________
Attorney Signature: _______________________________
Date: __________________
USCDNH-23A (11/00)(Previous Editions Obsolete)