VIRGINIA: IN THE CIRCUIT COURT FOR THE CITY OF VIRGINIA BEACH In re: Circuit Court Case No. : Assessment/Payment Order1 -- Costs of services of GAL for a child After review of the DC-40, the total amount allowed to the appointed guardian ad litem is $. Payment determinations of the parents for guardian ad litem services are as follows [GAL TO COMPLETE]: The father is to pay $0.00. Father determined to be indigent based on the Federal Poverty Guidelines; OR The father is to pay $ . The payment due date is: Name of father: Address of father: The mother is to pay $0.00. Mother determined to be indigent based on the Federal Poverty Guidelines; OR The mother is to pay $ . The payment due date is: Name of mother: Address of mother: [AND/OR] The party with a legitimate interest is to pay $ .The payment due date is: Name of party: Address of party: The payment to the guardian ad item shall be as follows [GAL TO CHECK ONE]: The guardian ad litem shall be paid from Commonwealth funds . The parent or parents shall reimburse the Commonwealth in the amount stated above. Payment shall be made to the Circuit Court Clerk, 2425 Nimmo Parkway, Virginia Beach, Virginia 23456-9017. Personal checks are not accepted. PRINT name and case number on the money order, certified or cashier check. If payment is not enclosed: (i) the assessed costs shall be docketed immediately as a judgment in the judgment lien docket book of the clerk222s office of this city and the judgment will be released as soon as payment is made and (ii) if no due date for payment is stated above, then payment is due within 60 days from the date of entry of this order. Failure to pay shall result in the unpaid amount being forwarded to a collection agent utilized by the Commonwealth. An additional collection remedy is authorized by the Setoff Dent Collection Act. By agreement, the parent or parents shall make payment directly to the guardian ad litem in the amount and by the payment date stated above. In the event payment is not made, the guardian ad litem may notice the parent(s) and this court for an order directing the payment from the Commonwealth, in which case a judgment may be docketed against the parent(s). The Clerk of this Court shall mail a copy of this order to the parent(s) or other party at the above address if payment required. ENTER: , JUDGE ENDORSEMENT: , Guardian Ad Litem Revised May 22, 2018-GAL for Child Reimburse Order 1 This order must be SUBMITTED by the GAL TO THE COURT WHEN DC-40 IS SUBMITTED. DC-40 will not be processed until there has been a determination of payment by the parents. The recommended practice is to provide this order at the conclusion of the court hearing for determination. See Chapter 7-OES Manual Guidelines for Payment of Guardians Ad Litem for Children. American LegalNet, Inc. www.FormsWorkFlow.com