Fill and Sign the Civil Case Trial Level Form

Additional File No.(s) File No. * Complete Name, Address, and SSN of indigent respondent on Side Two. . . . . . 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 COMPLETE FOR THIS FEE: (Attach detailed time sheets when required by judge. Time must be reported in decimals , not minutes.) NOTE: In assigned counsel cases, the applicant is always the individual attorn\ ey. 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. Date Attorney Appointed Name Of Indigent Client CIVIL CASE TRIAL LEVEL FEE APPLICATION ORDER FOR PAYMENT JUDGMENT AGAINST PARENT/GUARDIAN G.S. Ch. 7A, Art. 36; G.S. Ch. 7B, Subch. I; G.S. 122C-266(d), -268(d) Date Email Address Taxpayer ID No. (see Note) Payee (see Note) Name Of Applicant Travel (no. of miles) Copying (if in-house, no. of copies) Other (attach receipts if > $25) Total Expenses Total Time Claimed This Fee Time Out Of Court Time In Court Waiting Time In Court Name Of Judge Setting Fee Disposition Date (if final fee) Beginning Date This Fee Request Ending Date This Fee Request Prior Total Fees And Expenses Allowed By Judge Telephone No. Date Address Name Of Judge (type or print) Signature Of Judge Signature Of Applicant District Court Division Superior Court Division Before The Clerk In The General Court Of Justice STATE OF NORTH CAROLINA County 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 to: IDS Financial Services Division, Courier Box 56-10-50, Raleigh, NC, OR if co\ urier is not available, mail to P.O. Box 2448, Raleigh, NC 27602. 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 o\ f value of services rendered for the indigent. I certify that this infor\ mation 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 column\ s. In column 2, check the box that describes the most recent disposition. I. APPLICATION 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 Involuntary Commitment Upheld Initial Disposition Entered Voluntary Commitment Review Order Entered Held in Civil Contempt Permanency Planning Order Entered Held in Criminal Contempt Parental Rights Terminated Dismissed Declared Incompetent Discharged Guardianship Modified None (Attorney Withdrew) Other: 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) TPR (Respondent GAL) DSS Initiated TPR (Juvenile GAL, Program Conflict) (Use “Request for Payment of GAL Conflict Attorney Services” form) 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: \ 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. $ $ $ $ $ $ (Over) Note To Judge: You do not need to sign here if you enter judgment and sign Section IV on the reverse. $ $ II. ORDER TO PAY OR FIX VALUE OF SERVICES AOCG, Rev. 11,