STATE OF NORTH CAROLINA In The General Court Of Justice District Superior Court Division County File No. Additional File No.(s) Check Here If This Fee Application Covers Multiple Convictions Name And Address Of Indigent, Juvenile, Or Dependent Adult Full Social Security No. (required by G.S. 7A-455(d)) NON-CAPITAL CRIMINAL OR NON-CRIMINAL APPEALS FEE APPLICATION ORDER FOR PAYMENT JUDGMENT AGAINST INDIGENT OR PARENT/GUARDIAN submission of final appellate fee applications, as well as IDS' billing policies, available at www.ncids.org. INSTRUCTIONS: Applicant completes and signs Section I, and mails to: Office of Indigent Defense Services, 123 W. Main St., Suite 400, Durham, NC 27701. If this is an application for interim payment, the IDS Office will complete Section II and forward a copy of this form to the IDS Financial Services Office for payment. If this is an application for final payment, the IDS Office will complete Sections II and III, and forward the original form to the trial judge, and copies of the form to the defendant or respondent and the IDS Financial Services Office for payment. The trial judge then completes Sections IV and V. The Clerk dockets the judgment. Has No Social Security No. G.S. Ch. 7A, Art. 36; G.S. 122C-268(d), -286(d) NOTE: DO NOT use this form for capital cases or for non-capital criminal or non-criminal cases at the trial level. Attorneys should consult IDS Rule 3.3(b) for deadlines on the I. APPLICATION I, the undersigned assigned counsel public defender appellate defender IDS contract counsel, make application for payment and reimbursement of necessary expenses incurred, or for determination of value of services rendered for the indigent. I certify that this information is correct to the best of my knowledge. NATURE OF MOST SERIOUS CONVICTION OR PROCEEDING THAT WAS APPEALED: (check all that apply) Criminal Trial; or Guilty Plea Felony (most serious conviction): Class: Name Of Offense: Juvenile Delinquency Class Of Offense: Special Proceedings Incompetency Involuntary Commitment Abuse/Neglect/Dependency (Parent or Custodian) Other Court Court of Appeals Supreme Court Prior Total Fees And Expenses Allowed Misdemeanor (most serious conviction): Name Of Offense: Termination Of Parental Rights (Parent or Custodian) A/N/D or TPR (Guardian Ad Litem for Parent or Custodian) Ending Date This Fee Request Beginning Date This Fee Request COMPLETE FOR THIS FEE: This Fee Application Is: Total Time Claimed This Fee (Attach detailed time sheets. Time must be reported in decimals, not minutes.) $ Interim Travel Final . Name Of Presiding Judge At The Trial Level $ $ Copying Other Date Of Last Appellate Ruling $ Total Expenses $ COMPLETE IF THIS IS A FINAL FEE: Result On Appeal No Error/Affirmed Reversed And Remanded Conviction Vacated New Sentencing Hearing New Trial Other: Appeal Withdrawn (check all that apply) NOTE: In assigned counsel cases, the applicant is always the individual attorney. If payment is to be made to individual applicant, write "same" under Payee and give applicant's taxpayer ID No. (Federal Employer ID No. or, if no Federal Employer ID, SSN). If payment is to be made to applicant's firm, give firm name as Payee and firm's taxpayer ID No. Name Of Applicant Address Payee (see Note) Taxpayer ID No. (see Note) Email Address Telephone No. Date Signature Of Applicant II. AWARD OF PAYMENT OR DETERMINATION OF VALUE OF SERVICES The IDS Director FINDS that the "Total Amount" stated on Line 3 below be: (Assigned Counsel/GAL) paid by the State of North Carolina to the payee named above. (Public Defender/Appellate Defender/IDS Contractor) fixed as the value of legal services and other expenses of representation rendered by the applicant named above. 1. Fees Allowed/Value Of Services Rendered $ 2. Other Necessary Expenses Allowed By The IDS Director $ Date 3. TOTAL AMOUNT IDS Director Thomas K. Maher (Over) Signature Of IDS Director $ AOC-CR-426, Rev. 11/14 © 2014 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com III. SUM OF ATTORNEY AND SUPPORT SERVICE FEES AND EXPENSES NOTE: The Office of Indigent Defense Services completes this section. A. Attorney Fees And Necessary Expenses: SUBTOTAL A (sum of all attorney fees and expenses paid to this attorney, on this and all prior applications) ..................... B. Support Services Fees And Expenses: SUBTOTAL B (sum of all amounts incurred throughout the appeal) ............................................................................... GRAND TOTAL A + B (attorney fees and expenses, plus support services) $ $ $ IV. FINDINGS OF FACT AND JUDGMENT After written notice to the indigent named on the reverse or service of a summons on the responsible person named below, and opportunity to be heard, the Court finds that the indigent, juvenile, or dependent adult named on the reverse has previously been adjudged to be indigent, or is less than 18 years old, or if 18 years old or older, remains dependent on and domiciled with the responsible person named below; that he/she requested and has been provided counsel and other necessary expenses of representation; and that the applicant named on the reverse provided services and incurred expenses of which the money value is that stated in Section III above. NOTE: To enter judgment against indigent, check Option "A" and sign Section V. To enter judgment against parent, guardian, or trustee of juvenile or dependent adult, check Option "B" and sign Section V. NOTE: The trial court may not enter judgment for an amount greater than the Total amount in Section III above. A. (Judgment Against Indigent) The Court further finds that an order has been entered adjudicating the juvenile to be abused, neglected, or dependent, that an order has been entered terminating the parental rights of one or both of the juvenile's parents, that the respondent has been held in criminal contempt, or that a judgment of conviction has been entered against the indigent, and all of the matters raised on appeal have not been vacated, reversed, or remanded. If the juvenile has been adjudicated abused, neglected, or dependent or parental rights have been terminated, the Court further finds that the respondent is financially able to pay the fees and expenses set out on the reverse and should therefore be held responsible for reimbursing the State for the same. Based on all of the above findings, it is ORDERED that the State of North Carolina recover from the indigent the