COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. (TYPE OR PRINT IN BLACK INK) In The General Court Of Justice : District Court Division Superior Court Division : Before the Clerk STATE OF NORTH CAROLINA County Name Of Indigent Client Plaintiff(s) -against- *Complete name, address and SSN of indigent respondent or responsible person(s) on side 2. File No. Index No. Additional File Nos. Calendar No. : CIVIL CASE TRIAL LEVEL JUDICIAL SUBPOENA FEE APPLICATION : ORDER FOR PAYMENT JUDGMENT AGAINST PARENT/GUARDIAN : G.S. Ch. 7A, Art. 36; G.S. Ch. 7B, Subch. I; G.S. 122C-268(d), -266(d) NOTE: Use this form ONLY for civil cases at the trial level, including child support contempt cases that end in a finding of criminal contempt. DO NOT use this form for criminal cases, juvenile delinquency cases, or appeals. Attorneys should consult IDS Rule 1.9(a)(1) for deadlines on the submission of final fee applications. : INSTRUCTIONS: Applicant completes and signs all applicable portions of Section I. If no judgment is entered, trial judge completes and signs Section II only. If judgment is entered, trial judge completes but does not sign Section II, then completes Section III and signs Section IV. Clerk mails private appointed counsel fee applications Defendant(s) : to: Administrative Office of the Courts, Attn: Indigent Program, Financial Services Division, Courier Box 56-10-50, Raleigh, NC, OR if courier is not available, mail to P.O. Box .. . .... 2448, Raleigh,.NC. 27602. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I. APPLICATION I, the undersigned assigned counsel public defender IDS contract counsel guardian ad litem make application for payment and reimbursement of necessary expenses incurred, or for determination of value of services rendered for the indigent. I certify THE PEOPLE OF to the best of my knowledge. that this information is correct THE STATE OF NEW YORK ORIGINAL PROCEEDING AND DISPOSITION: In the applicable section below, check ONE box in each of the two columns. In column 2, check the box that describes the most recent disposition. TO A. Appointed Attorneys ONLY (Complete B. below if you are a guardian ad litem.) 1. Original Proceeding 2. Disposition Abuse/Neglect/Dependency TPR GREETINGS: Competency Civil Commitment Child Support Contempt WE COMMAND Other Civil Contempt the Honorable Other: YOU, that all (most recent disposition) Adjudicated Abused, Neglected, or Dependent Initial Disposition Entered Review Order Entered Initial Permanency Planning Order Entered Parental Rights Terminated business and excuses being laid aside, you Declared Incompetent Court Other: at the Involuntary Commitment Upheld Voluntary Commitment Held in Civil Contempt Held in Criminal Contempt Dismissed and each of you attend before Discharged None (Attorney Withdrew) located at County Litem B. Guardians Adof in room , on the day of , 20 , (most o'clock noon, and at any recessed 1. Original Proceeding 2. Disposition at recent disposition) in the or adjourned date, (Respondent GAL) part of the Abuse/Neglect/Dependency to testify and give evidence as a witness in this action on theor Dependent Adjudicated Abused, Neglected, Declared Incompetent Abuse/Neglect/Dependency (Juvenile GAL, Program Conflict) Initial Disposition Entered Dismissed TPR (Respondent GAL) Review Order Entered None (Attorney Withdrew) DSS Initiated TPR (Juvenile GAL, Program Conflict) Initial Permanency Planning Order Entered Private TPR (Juvenile GAL) (charge to AOC) Parental Rights Terminated Your failure Competency (Respondent GAL) to comply with this subpoena is punishable as a contempt of court and will make you liable to the party for a Other: (specify) on whose behalf this subpoena was issued Other: maximum penalty of $50 and all damages sustained as a result of your failure to comply. Beginning Date This Fee Requested COMPLETE FOR THIS FEE: (Attach Prior Total Fees And Expenses Allowed By Judge Ending Date This Fee Requested $ detailed time sheets Disposition Date (if final fee) Time In Court Witness, Honorable when required by judge. Time must be Court Name Of Judge Setting Fee County, Travel day of reported in decimals, in not minutes.) . $ Time In Court Waiting . Time Out Of Court . , 20 Long Distance Telephone Copying . Other Total Expenses $ $ $ Total Time Claimed This Fee , one of the Justices of the $ 0.00 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. Address Name Of Applicant (Attorney must sign above and type name below) Payee (see note) Taxpayer ID No. (see note) Date Telephone No. Signature Of Applicant Attorney(s) for II. ORDER TO PAY OR FIX VALUE OF SERVICES Based on the Findings of Fact set out in Section III, the Court ORDERS that the "Total Amount" stated on Line 4 below be: (Assigned Counsel/GAL) paid by the State of North Carolina to the payee above. (Public Defender/IDS Contractor) fixed as the value of legal services and other expenses of representation rendered by the applicant above. Office and P.O. Address 1. Hours Approved By The Court 2. Fees Allowed/Value Of Services Rendered (Hours Approved x IDS Rate) = 3. Other Necessary Expenses Allowed By The Court 4. TOTAL AMOUNT Date Name Of Judge (Type Or Print) (Over) AOC-G-200, Rev. 4/06, © 2006 Administrative Office of the Courts . $ $ Telephone No.: Facsimile No.: $ Signature Of Judge E-Mail Address: Note To Judge: You do not need to sign here if you enter judgment and Mobile Tel. No.: sign Section IV on the reverse. American LegalNet, Inc. www.FormsWorkflow.com , COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : III. FINDINGS OF FACT AND JUDGMENT No. Index To enter judgment against the respondent or a responsible person(s) named below, the Court must make one of the following : Calendar No. three findings and sign below: 1. This is a juvenile abuse, neglect or dependency proceeding; the applicant is an attorney advocate or guardian ad litem appointed : JUDICIAL SUBPOENA under G.S. 7B-601 or 7B-602; and the juvenile has Plaintiff(s) been adjudicated abused, neglected or dependent; or 2. This is a proceeding on a motion for termination of parental rights filed in a:juvenile abuse, neglect or dependency proceeding; -againstthe applicant is an attorney advocate or guardian ad litem appointed under G.S. 7B-1101.1 or 7B-1108; and the parental rights of one or both of the juvenile's parents have been terminated. : 3. This is a child support contempt proceeding; the applicant is an attorney appointed to represent the respondent in this proceeding; and the respondent has been held in criminal contempt. : After due notice to the respondent named below or serviceDefendant(s) on the responsible person(s) named below, and opportunity to of a summons : be heard,. the.Court finds. that the. indigent. client named .on. the .reverse . . . . . . . . and has been provided counsel and other necessary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . requested . expenses of representation; that the applicant named on the reverse provided services and incurred expenses of which the money value is that stated in Section II on Line 4, plus any interim fees listed in the box in Section I labeled "Prior Total Fees And Expenses Allowed By Judge;" and that the respondent or the responsible parent, guardian or trustee of the juvenile who is named below is financially able to pay the fees and expenses set out on the reverse, and should be held responsible for reimbursing the State for the same. THE PEOPLE OF THE STATE OF NEW YORK Therefore, it is ORDERED that the respondent or responsible person(s) shall reimburse the State the TOTAL AMOUNT stated in Section II on Line 4, plus any interim fees listed in the box in Section I labeled "Prior Total Fees And Expenses Allowed By Judge," by TO paying the same to the Clerk of Superior Court for transmittal to the State Treasurer. If that amount is not paid in full at the time of disposition, this judgment shall be docketed and the State of North Carolina shall then recover from the respondent or responsible person(s) that amount together with interest at the legal rate from the date of docketing until paid. Name And Address Of Respondent (Complete if appointed attorney or GAL represented parent/guardian) GREETINGS: Social Security No. - - WE COMMAND YOU, that all business and excuses being laid aside, youHas Noeach of youNo. and Social Security attend before , the Honorable at the Court located at County of OR in room , on (Complete if appointed attorney or GAL ,represented child) day of 20 , at o'clock inSocial Security No. and at any recessed the noon, Name And Address Of Responsible Person 1the or adjourned date, to testify and give evidence as a witness in this action on the part of the Has No Social Security No. Name And Address Of Responsible Person 2 (Complete if appointed attorney or GAL represented child) Social Security No. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Has No Social Security No. result of your failure to comply. IV. SIGNATURE OF JUDGE Witness, Honorable , one and JUDGMENT shall The foregoing ORDER TO PAY APPLICANT OR FIX VALUE OF SERVICES, FINDINGSof the Justices of the be entered and filed this day in the office of the Clerk of Superior Court. The Judgment shall become effective as provided Court in County, day of , 20 by law. Date Name Of Judge (Type Or Print) Signature Of Presiding Judge (Attorney must sign above and type name below) V. DOCKETING - CSC USE ONLY NOTE: Do not docket this judgment if, at the time of disposition, the respondent or responsible person(s) named above pays to the Clerk of Superior Court the "Total Amount" stated in Section II on Line 4, plus any interim fees listed in the box in Section I labeled "Prior Total Fees And Expenses Allowed By Judge." Docket this judgment for Attorney(s) at disposition if the respondent or responsible person(s) does not make such payment. Date Judgment Docket Book And Page No. Time AM Abstract No. Amount Docketed $ PM Office and P.O. Address AOC-G-200, Side Two, Rev. 4/06 © 2006 Administrative Office of the Courts Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.FormsWorkflow.com