STATE OF NORTH CAROLINA Name Of Indigent Client Date Attorney Appointed In The General Court Of Justice District Court Division Superior Court Division County Before The Clerk File No. Additional File No.(s) * Complete Name, Address, and SSN of indigent respondent on Side Two. 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 to: IDS 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. G.S. Ch. 7A, Art. 36; G.S. Ch. 7B, Subch. I; G.S. 122C-266(d), -268(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 CIVIL CASE TRIAL LEVEL FEE APPLICATION ORDER FOR PAYMENT JUDGMENT AGAINST PARENT/GUARDIAN 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 that this information is correct to the best of my knowledge. 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. A. Appointed Attorneys ONLY (Complete B below if you are a guardian ad litem.) 1. Original Proceeding Abuse/Neglect/Dependency TPR Competency Modification of Guardianship (Incompetent Ward) Civil Commitment Child Support Contempt Other Civil Contempt Other: 2. Disposition (most recent disposition) Adjudicated Abused, Neglect, or Dependent Initial Disposition Entered Review Order Entered Permanency Planning Order Entered Parental Rights Terminated Declared Incompetent Guardianship Modified Other: Involuntary Commitment Upheld Voluntary Commitment Held in Civil Contempt Held in Criminal Contempt Dismissed Discharged None (Attorney Withdrew) B. Guardians Ad Litem 1. Original Proceeding Abuse/Neglect/Dependency (Respondent GAL) Abuse/Neglect/Dependency (Juvenile GAL, Program Conflict) (Use "Request for Payment of GAL Conflict Attorney Services" form) (Use "Request for Payment of GAL Conflict Attorney Services" form) TPR (Respondent GAL) DSS Initiated TPR (Juvenile GAL, Program Conflict) Private TPR (Juvenile GAL) (charge to AOC) Competency (Respondent GAL) Modification of Guardianship (Incompetent Ward) Other: (specify) 2. Disposition (most recent disposition) Adjudicated Abused, Neglect, or Dependent Dismissed Initial Disposition Entered None (Attorney Withdrew) Review Order Entered Permanency Planning Order Entered Parental Rights Terminated Declared Incompetent Guardianship Modified Other: Disposition Date (if final fee) Prior Total Fees And Expenses Allowed By Judge COMPLETE FOR Beginning Date This Fee Request THIS FEE: (Attach Ending Date This Fee Request Time In Court Copying detailed time sheets Name Of Judge Setting Fee when required by judge. Time must be reported in decimals, Travel (no. of miles) not minutes.) $ . Time In Court Waiting . Time Out Of Court $ . Total Time Claimed This Fee . 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 Payee (see Note) Taxpayer ID No. (see Note) Email Address Telephone No. Date Signature Of Applicant 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 $ (if in-house, no. of copies) Other (attach receipts if > $25) $ Total Expenses $ 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 named above. (Public Defender/IDS Contractor) fixed as the value of legal services and other expenses of representation rendered by the applicant named above. 1. Hours Approved By The Court 2. Fees Allowed/Value Of Services Rendered 3. Other Necessary Expenses Allowed By The Court . (Hours Approved x IDS Rate) = II. ORDER TO PAY OR FIX VALUE OF SERVICES 4. TOTAL AMOUNT Date Name Of Judge (type or print) (Over) Signature Of Judge on the reverse. $ $ $ AOC-G-200, Rev. 10/14, � 2014 Administrative Office of the Courts Note To Judge: You do not need to sign here if you enter judgment and sign Section IV American LegalNet, Inc. www.FormsWorkFlow.com III. FINDINGS OF FACT AND JUDGMENT To enter judgment against the respondent named below, the Court must make one of the following three findings and sign below: 1. This is a juvenile abuse, neglect or dependency proceeding, the applicant is an attorney appointed under G.S. 7B-602, and the juvenile has been adjudicated abused, neglected or dependent. 2. This is a proceeding on a motion or petition for termination of parental rights, the applicant is an attorney appointed under G.S. 7B-1101.1, 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, and opportunity to be heard, the Court finds that the indigent client named on the reverse requested and has been provided counsel and other necessary 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 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. Therefore, it is ORDERED that the respondent shall reimburse the State the