Fill and Sign the For Payment to Arbitrator Form

STATE OF NORTH CAROLINA File No. A PPL ICA TIO N VE RSUS ORD ER FOR U SE BY AOC FI NANCIAL SE RVICE S DIVIS ION Trav el (I n-State @ State Rate x Mile s) .................. . APPLICA TIO N AND ORD ER FO R PAYMEN T TO ARBITRA TOR Coun ty ARBITRATION G. S. 7A-37.1 ; Rule 4 , Rules For Court-Or dered Arbi tration in North Carolina AOC- CV-804 , Rev . 2/12 © 2012 Adminis trative Office o f the Cou rts In T he Gene ral Cou rt Of Justice District Court Di vis ion Purs uant to Rule 4(c) of t he Rule s For Cou rt-Or dered Ar bitrat ion in North Carolina , I, the unde rsigned arbitrato r, appl y f or payment of a fee and for r eim bu rsem ent for tr avel ex pen ses as prov ided for in the Rule s. An ar bitrat ion hea rin g The Cou rt ORDERS tha t the ar bitrato r na med abo ve be paid as follow s: Signature Of Arbitrator Signature Of Judge Fee ($100 i f award made ; reasonable fee no t to exceed $100 i f no t.) ......... . Tot al Am ount ............................................................................ . NOTE:This paym ent will be repo rted annua lly to IRS for income tax pu rpo ses, if applicab le. $ $ $ Approval For Payment Signature INSTRUCTIONS: Arbitrato r prepares in dup licate fo r judge's signature . Clerk o f Superio r Cou rt files the original and ma ils ce rtified copy to the Adminis trative Office o f the Cou rts, A ttn: Financia l Services Division ,P .O. Box 2448 , Raleigh , NC 27602 , OR sends by State Courie r Service. COMP ANY ACC OUN T CEN TER AMO UNT Name Of Defendant(s) Name Of Plaintiff(s) Date Taxpayer ID No. (Social Security No.) Name And Address Of Arbitrator Date Name Of Judge (Type Or Print) Date was held and an awa rd wa s m ade in the abo ve-entitled case. wa s ini tia ted and the ar bitrato r na med abo ve was c hosen for t he abo ve-entitled case ; howe ver, t he ar bitrat ion proc eeding did no t res ult in a com pleted hea ring or an awa rd.