Fill and Sign the Electronic Course Materials Unc School of Government Form

NOTE: Use this form ONLY for juvenile delinquency cases at the trial level. DO NOT use this form for criminal cases, or appeals to the Court of Appeals or Supreme Court. Attorneys should consult IDS Rule 1.9(a)(1a) for deadlines on the submission of �nal 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: Administrative Of�ce of the Courts, Attn: Indigent Program, Financial Services Division, Courier Box 56-10-50, Raleigh, NC, OR if courier is not available, mail to PO Box 2448, Raleigh, NC 27602. Additional File No.(s) File No. District Court Division In The General Court Of Justice (TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA County Name And Address Of Juvenile 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 taxpayer ID No. (either Federal Employer ID No. or, if no Federal Employer ID No., SSN). If payment is to be made to applicant’s �rm, give �rm name as payee and �rm’s taxpayer ID No. JUVENILE DELINQUENCY TRIAL LEVEL FEE APPLICATION ORDER FOR PAYMENT JUDGMENT AGAINST PARENT/GUARDIAN Date Attorney Appointed *Complete name, address and SSN of responsible person(s) on Side Two. G.S. Ch. 7A, Art. 36; G.S. Ch. 7B, Subch. II 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) paid by the State of North Carolina to the payee above. (Public Defender/IDS Contractor) �xed as the value of legal services and other expenses of representation rendered by the applicant above. Email Address Taxpayer ID No. (see Note) Payee (see Note) Name Of Applicant Telephone No.Date Address Signature Of Applicant II. ORDER TO PAY OR FIX VALUE OF SERVICES COMPLETE FOR THIS FEE: (Attach detailed time sheets when required by judge. Time must be reported in decimals, not minutes.) Other (attach receipts if > $25) Disposition Date Name Of Judge Setting Fee Total Expenses$ Travel (no. of miles) $ Copying (if in-house, no. of copies)$ $ Time In Court . Time In Court Waiting . 2. Fees Allowed/Value Of Services Rendered (Hours Approved x IDS Rate) = (Over) Note To Judge: You do not need to sign here if you enter judgment and sign Section IV on the reverse. 1. Hours Approved By The Court 3. Other Necessary Expenses Allowed By The Court 4. TOTAL AMOUNT $ $ Date Name Of Judge (type or print) Signature Of Judge $ . Time Out Of Court . Total Time Claimed This Fee . I, the undersigned assigned counsel public defender IDS contract counsel 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: Check ONE box in each of the following 3 columns. In columns 2 and 3, check the one box that describes the most recent resolution and disposition. I. APPLICATION 1. Original Charge (most serious offense) Felony Offense Must indicate Felony Class: Name of Offense: Misdemeanor Offense Must indicate Misd. Class: Name of Offense: Motion For Review (Probation Viol.) Motion For Review (Other) (in columns 2 and 3, check Other) Status Review (in columns 2 and 3, check Other) Detention Hearing (Limited Appear.) (in columns 2 and 3, check Other) Drug Treatment Court (in columns 2 and 3, check Other) Other: 2. Resolution Of Charges (most serious resolution) Admission: Most Serious Original Charge Admission: Other Offense Name of Offense: Adjudicatory Hearing: Responsible - Most Serious Original Charge Adjudicatory Hearing: Responsible - Other Offense Name of Offense: Adjudicatory Hearing: Not Responsible Probation Violation Found Case Transferred To Superior Court (Waiver) Case Transferred To Superior Court (Contested) Dismissed With Leave Dismissed Without Leave Continued Adjudication (Admission) None (Attorney Withdrew ) Other: 3. Disposition (most serious disposition) Commitment To YDC Out-Of-Home Placement DSS Custody Detention/Intermittent Con�nement Number of days: Probation None (Transferred To Superior Court) None (Not Responsible/Dismissed) None (Continued Adjudication) None (No Disposition Entered) None (Attorney Withdrew ) Other: NC-JOIN No. AOC-J-411, Rev. 12/17, © 2017 Administrative Of�ce of the Courts III. FINDINGS OF FACT AND JUDGMENT To enter judgment against a responsible person(s), the Court must make the following �nding and sign below: This is a juvenile delinquency proceeding; the applicant is an attorney appointed to represent the juvenile in this proceeding under G.S. 7B-2000; and the juvenile has been adjudicated delinquent. After service of a summons on the responsible person(s) named below, and opportunity to be heard, the Court �nds that the indigent juvenile 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; and that the responsible person(s) named below is the parent, guardian or trustee of the juvenile, is �nancially 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 responsible person(s) shall reimburse the State the TOTAL AMOUNT stated in Section II on Line 4, by paying the same to the Clerk of Superior Court for transmittal to the State Treasurer. If that amount is not paid in full at the time of disposition, this judgment shall be docketed and the State of North Carolina shall then recover from the responsible person(s) that amount together with interest at the legal rate from the date of docketing until paid. IV. SIGNATURE OF JUDGE The foregoing ORDER TO PAY APPLICANT OR FIX VALUE OF SERVICES, FINDINGS and JUDGMENT shall be entered and �led this day in the of�ce of the Clerk of Superior Court. The Judgment shall become effective as provided by law. V. DOCKETING - CSC USE ONLY NOTE: Do not docket this judgment if, at the time of disposition, the responsible person(s) named above pays to the Clerk of Superior Court the “Total Amount” stated in Section II on Line 4. Docket this judgment at disposition if the responsible person(s) does not make such payment. Date Name Of Judge (type or print) Signature Of Presiding Judge Date Time Amount Docketed Judgment Abstract No. AM PM $ Name And Address Of Responsible Person 1 Name And Address Of Responsible Person 2 Social Security No. Has No Social Security No. - - Social Security No. Has No Social Security No. - - AOC-J-411, Side Two, Rev. 12/17 © 2017 Administrative Of�ce of the Courts