STATE OF NORTH CAROLINA County Name Of Plaintiff(s) File No. In The General Court Of Justice District Court Division ARBITRATION Name Of Defendant(s) VERSUS APPLICATION AND ORDER FOR PAYMENT TO ARBITRATOR G.S. 7A-37.1; Rule 4, Rules For Court-Ordered Arbitration in North Carolina APPLICATION Pursuant to Rule 4(c) of the Rules For Court-Ordered Arbitration in North Carolina, I, the undersigned arbitrator, apply for payment of a fee and for reimbursement for travel expenses as provided for in the Rules. An arbitration hearing was held and an award was made in the above-entitled case. was initiated and the arbitrator named above was chosen for the above-entitled case; however, the arbitration proceeding did not result in a completed hearing or an award. Date Taxpayer ID No. (Social Security No.) Signature Of Arbitrator Name And Address Of Arbitrator ORDER The Court ORDERS that the arbitrator named above be paid as follows: Fee ($100 if award made; reasonable fee not to exceed $100 if not.) .......... Travel (In-State @ State Rate x Miles) ................... $ $ $ Signature Of Judge Total Amount ............................................................................. Date Name Of Judge (Type Or Print) NOTE: This payment will be reported annually to IRS for income tax purposes, if applicable. COMPANY FOR USE BY AOC FINANCIAL SERVICES DIVISION ACCOUNT CENTER AMOUNT Date Approval For Payment Signature INSTRUCTIONS: Arbitrator prepares in duplicate for judge's signature. Clerk of Superior Court files the original and mails certified copy to the Administrative Office of the Courts, Attn: Financial Services Division, P.O. Box 2448, Raleigh, NC 27602, OR sends by State Courier Service. AOC-CV-804, Rev. 2/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com