NOTICE TO GUARDIAN AD LITEM: In order to comply with Item 34(G) of the 2002 Appropriation Act, this order must be COMPLETED and submitted to the court when your 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. If not provided at court hearing have parents, or their counsel, endorse the order. VIRGINIA: IN THE CIRCUIT COURT FOR THE CITY OF VIRGINIA BEACH IN RE: _______________________________________________________________________________________ Circuit Court Case No. : _________________________ ORDER -- GUARDIAN AD LITEM COSTS FOR A CHILD After review of the DC-40 submitted by the guardian ad litem, the total amount allowed to _________________________________________ , appointed guardian ad litem for a child in this case, is $_______________. PAYMENT DETERMINATIONS FOR GUARDIAN AD LITEM’S SERVICES THIS SECTION TO BE COMPLETED BY GAL OR COUNSEL: The father, _______________________________________________________, is to pay $ ___________________________ [CHECK ONE] □ Payment due date: ________________________ □ Payment enclosed. ADDRESS: ____________________________________________________________________________________________ [OR] □ After review of the Federal Poverty Guidelines, the father is indigent and does not have to pay. THIS SECTION TO BE COMPLETED BY GAL OR COUNSEL: The mother, ______________________________________________________, is to pay: $__________________________ [CHECK ONE] □ Payment due date: ________________________ □ Payment enclosed. ADDRESS: ____________________________________________________________________________________________ [OR] □ After review of the Federal Poverty Guidelines, the mother is indigent and does not have to pay. IF PAYMENT REQUIRED, GAL OR COUNSEL TO CHECK ONE BOX BELOW AS TO HOW PAYMENT TO BE MADE: □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 clerk’s 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 attorney for the Commonwealth and be offset against any tax refund, lottery winnings or other funds due you from the Commonwealth. □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) at the above address if payment required. ENTER: ____________________________ ____________________________________, JUDGE ENDORSEMENTS: _______________________________ Guardian Ad Litem _______ _____________________________ Father/Counsel Revised October 1, 2005 GAL for Child Reimburse Order ________________________________ Mother/Counsel American LegalNet, Inc. www.FormsWorkflow.com