File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County Name Of Juvenile IN THE MATTER OF: Date Of Birth SUPPLEMENTAL ORDER TO PARENT, GUARDIAN OR CUSTODIAN OF UNDISCIPLINED OR DELINQUENT JUVENILE Age G.S. 7B-2700 through -2706 ORDER DIRECTED TO: who is/are the [name person(s)], mother father guardian custodian of the juvenile named above. FINDINGS In addition to the findings of fact in the Dispositional Order or other Order to which this Supplemental Order is attached and of which this Order is a part, the Court makes the following findings of fact specifically in support of this Supplemental Order: (State additional findings, if any.) CONCLUSIONS OF LAW The Court concludes as a matter of law that the Court has jurisdiction and authority to direct this Order to the person(s) named above. ORDER The Court hereby ORDERS you, the person(s) named above: 1. Attend Hearings [G.S. 7B-2700]. To attend all hearings in this matter of which you receive notice, including notice given in open court, except as specifically described below: (Describe any extent to which the person(s) is/are excused from attending one or more hearings.) 2. Provide Transportation [G.S. 7B-2703(a)]. To provide transportation for the juvenile to keep appointments with the court counselor and comply with other orders of the Court, as follows: 3. Help Juvenile Comply With Orders [G.S. 7B-2703(b)]. To assist the juvenile in complying with the terms and conditions of probation, protective supervision, or other orders of the Court. Specifically, (add any specific requirements) : 4. Parental Responsibility Classes [G.S. 7B-2701]. To attend parental responsibility classes, as follows: AOC-J-463, New 7/99 1999 Administrative Office of the Courts (Over) 2001 © American LegalNet, Inc. 5. Pay Costs Of Juvenile's Evaluation/Treatment [G.S. 7B-2502, -2702(a)]. NOTE: This Order may be directed only to a parent or other responsible party, and must be supported by findings that the person is able to pay the cost. To pay the cost of the evaluation or treatment described below, which the Court has ordered for the juvenile pursuant to G.S. 7B-2502: (Describe evaluation or treatment and specify any details of payment responsibility.) 6. Participate In Juvenile's Treatment [G.S. 7B-2702(b)]. NOTE: This Order may be directed only to a parent. To participate in the evaluation or treatment the Court has ordered for the juvenile, as follows: 7. Undergo (And Pay For) Evaluation, Treatment, Or Counseling [G.S. 7B-2702(c), (d)]. NOTE: This Order may be directed only to a parent. a. To comply with the plan of evaluation, treatment, or counseling described below. b. To retain or assume legal custody physical placement of the juvenile on the condition that you comply with the plan of evaluation, treatment, or counseling described below: c. To pay for the evaluation, treatment, or counseling described above to the following extent: (requires findings as to parent's ability to pay) 8. Payment Of Support And/Or Other Expenses [G.S. 7B-2704]. NOTE: This Order may be directed only to a parent and requires findings that the parent is able to pay the amount(s) ordered. a. To pay to the North Carolina Centralized Collection Office $ per month, for the support of the juvenile (requires findings to show that amount was determined as provided in G.S. 50-13.4). A completed copy of AOC-CV-640 Cover Sheet For Child Support Cases (Non-IV-D Only) and AOC-CV-618 Order To Withhold Wages To Enforce Child Support must be attached. b. To pay into the office of the Clerk of Superior Court of the County named above: 1. $ per month, for probation supervision. 2. $ per month, for residential facility costs. 3. $ , on or before (date) , for court-appointed attorney's fees. The Clerk shall distribute these payments as follows: 9. Assignment Of Insurance [G.S. 7B-2704]. To assign private insurance coverage to to cover medical costs while the juvenile is in an out-of-home placement. Date Name Of District Court Judge (Type Or Print) , Signature Of District Court Judge NOTICE: This order is issued pursuant to Article 27 of Chapter 7B of the North Carolina General Statutes, which includes the following provision: "§ 7B-2705. Employment discrimination unlawful. No employer may discharge, demote, or deny a promotion or other benefit of employment to any employee because the employee complies with the provisions of this Article. The Commissioner of Labor shall enforce the provisions of this section according to Article 21 of Chapter 95 of the General Statutes, including the rules and regulations issued pursuant to that Article." AOC-J-463, Side Two, New 7/99 1999 Administrative Office of the Courts 2001 © American LegalNet, Inc.