NO. _________

IN THE (SUPREME COURT or INTERMEDIATE COURT OF APPEALS)

OF THE STATE OF HAWAI'I

_______________________________,

Plaintiff-_____________,

v.

______________________________,

Defendant-___________.

__________________________________	)
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)	____________ NO. _______

REQUEST AND DECLARATION OF COUNSEL

In accordance with Hawai i Rules of Appellate Procedure (HRAP) Rule 39(d), I, ___________________________, attorney for __________________, request compensation for costs and attorneys' fees and, in conjunction herewith aver, as follows:

1. (Appellant or Appellee) prevailed in this appeal.

2. I request reimbursement for necessary and authorized costs as follows:

Item	Amount	Authority

a.	$ ____________

b.	$ ____________

c.	$ ____________

d. _	$ ___________

TOTAL COSTS	$

A true and correct itemized accounting of these costs, including relevant invoices and receipts, is attached as Appendix A.

HRAP Form 8 (09/10)	Page 1

3. I have expended the following hours in attorney work and, pursuant to Hawaii Revised Statutes or , am entitled to charge the following amounts for this appeal:

Activity	Hours	Amount

a. Correspondence, Interviews and Conferences	______ @ $ _______	$ _______

b. Obtaining & Reviewing Records	______ @ $ _______	$ _______

c. Legal Research	______ @ $ _______	$ _______

d. Drafting	______ @ $ _______	$ _______

e. Oral Argument (In-court)	______ @ $ _______	$ _______

f. Other (Specify)	______ @ $ _______	$ _______

TOTAL FEES	______	$ _______

Attached hereto as Appendix B are hourly worksheets, prepared in accordance with HRAP Form 8 and contemporaneously with the work performed as noted thereon and truthfully reflecting the amount of work actually performed in the representation of (Appellant or Appellee) . Additional information [including the language of the contract authorizing attorneys' fees] and authority [including appropriate case authority] supporting my request for costs and attorneys' fees is included in the memorandum of law attached hereto.

I, _______________________, declare under penalty of law, as provided by HRAP Rule 52, that the foregoing is true and correct.

DATED: ______________________________________________.

__________________________________

HRAP Form 8 (09/10)	Page 2