Form AOC-J-226 "Affidavit of Indigency (Juvenile Proceedings)" - North Carolina

What Is Form AOC-J-226?

This is a legal form that was released by the North Carolina District Court - a government authority operating within North Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the North Carolina District Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-J-226 by clicking the link below or browse more documents and templates provided by the North Carolina District Court.

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Download Form AOC-J-226 "Affidavit of Indigency (Juvenile Proceedings)" - North Carolina

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File No.
In The General Court Of Justice
(TYPE OR PRINT IN BLACK INK)
District Court Division
Additional File Nos.
STATE OF NORTH CAROLINA
County
Name Of Parent
AFFIDAVIT OF INDIGENCY
(JUVENILE PROCEEDINGS)
Street Number And Street Name, Including Apartment Or Unit Number If Applicable
G.S. 7A-450 et seq., 7B-602, -2503(1)c., -2506(1)c.
Allegation(s)
Abuse
Neglect
Dependency
Adjudication(s)
Delinquent (for post-DSS-placement review and
City, State And Zip Code
permanency planning hearings)
Undisciplined (for post-DSS-placement review and
permanency planning hearings)
Full Permanent Mailing Address Of Parent (if different than above)
Parent: Have you ever had an attorney appointed to represent you
Telephone Number Of Parent
Date Of Birth
in a juvenile abuse/neglect/dependency action regarding the same
or different child(ren)?
Yes
No
Full Social Security No. Of Parent
-
-
Has No Social Security No.
MONTHLY INCOME (money you make)
MONTHLY EXPENSES (money you pay out)
$
Employment - Parent
Number Of Dependents
Name And Address Of Parent’s Employer
$
Shelter
Buying
Renting
(If not employed, state reason; if self-employed, state trade)
Food
$
(including Food Stamps)
Utilities
(power, water, heating,
$
phone, cable, etc.)
Health Care
$
Other Income
(Welfare, Food Stamps,
$
S/S, Pensions, etc.)
Installment Payments
$
Vehicle
Other
Employment - Spouse
$
Car Expenses
$
Name And Address Of Spouse’s Employer
(gas, insurance, etc.)
Support Payments
$
Other:
(specify)
$
Total Monthly Income
$
Total Monthly Expenses
$
ASSETS
LIABILITIES
DESCRIPTION OF ASSETS AND LIABILITIES
(things you own)
(amounts you owe)
Cash On Hand And In Bank Accounts
$
(list name of bank and account type, do not list account no.)
Money Owed To Or Held For Parent
$
Motor Vehicles
(Fair Market Value)
(Balance Due)
(list make, model, year)
$
$
(Fair Market Value)
(Balance Due)
Real Estate
$
$
(Balance Due)
(Fair Market Value)
Personal Property
$
$
Other Debts
$
$
$
Last Income Tax Filed 20
Refund
Owe
Other
$
$
Total Assets And Liabilities
$
$
Bond Type
Amount
By Whom Posted
$
NOTE:
Read the notice on the reverse side before completing this form.
AOC-J-226, Rev. 6/21, © 2021 Administrative Office of the Courts
(Over)
File No.
In The General Court Of Justice
(TYPE OR PRINT IN BLACK INK)
District Court Division
Additional File Nos.
STATE OF NORTH CAROLINA
County
Name Of Parent
AFFIDAVIT OF INDIGENCY
(JUVENILE PROCEEDINGS)
Street Number And Street Name, Including Apartment Or Unit Number If Applicable
G.S. 7A-450 et seq., 7B-602, -2503(1)c., -2506(1)c.
Allegation(s)
Abuse
Neglect
Dependency
Adjudication(s)
Delinquent (for post-DSS-placement review and
City, State And Zip Code
permanency planning hearings)
Undisciplined (for post-DSS-placement review and
permanency planning hearings)
Full Permanent Mailing Address Of Parent (if different than above)
Parent: Have you ever had an attorney appointed to represent you
Telephone Number Of Parent
Date Of Birth
in a juvenile abuse/neglect/dependency action regarding the same
or different child(ren)?
Yes
No
Full Social Security No. Of Parent
-
-
Has No Social Security No.
MONTHLY INCOME (money you make)
MONTHLY EXPENSES (money you pay out)
$
Employment - Parent
Number Of Dependents
Name And Address Of Parent’s Employer
$
Shelter
Buying
Renting
(If not employed, state reason; if self-employed, state trade)
Food
$
(including Food Stamps)
Utilities
(power, water, heating,
$
phone, cable, etc.)
Health Care
$
Other Income
(Welfare, Food Stamps,
$
S/S, Pensions, etc.)
Installment Payments
$
Vehicle
Other
Employment - Spouse
$
Car Expenses
$
Name And Address Of Spouse’s Employer
(gas, insurance, etc.)
Support Payments
$
Other:
(specify)
$
Total Monthly Income
$
Total Monthly Expenses
$
ASSETS
LIABILITIES
DESCRIPTION OF ASSETS AND LIABILITIES
(things you own)
(amounts you owe)
Cash On Hand And In Bank Accounts
$
(list name of bank and account type, do not list account no.)
Money Owed To Or Held For Parent
$
Motor Vehicles
(Fair Market Value)
(Balance Due)
(list make, model, year)
$
$
(Fair Market Value)
(Balance Due)
Real Estate
$
$
(Balance Due)
(Fair Market Value)
Personal Property
$
$
Other Debts
$
$
$
Last Income Tax Filed 20
Refund
Owe
Other
$
$
Total Assets And Liabilities
$
$
Bond Type
Amount
By Whom Posted
$
NOTE:
Read the notice on the reverse side before completing this form.
AOC-J-226, Rev. 6/21, © 2021 Administrative Office of the Courts
(Over)
NOTICE TO PERSONS REQUESTING A COURT-APPOINTED LAWYER
1. When answering the questions on the Affidavit Of Indigency (reverse side of this form), please do not discuss your case with the
interviewer. The interviewer can be called as a witness to testify about any statements made in his/her presence. Please wait and
speak with your lawyer. Do not ask the interviewer for any advice or opinion concerning your case.
2. A COURT-APPOINTED LAWYER IS NOT FREE. If your child is adjudicated abused, neglected, or dependent or, if your
parental rights are terminated, the Court may require you to pay the fees of court-appointed counsel as authorized by
G.S. 7B-603. The Court may also enter a civil judgment against you, which will accrue interest at the legal rate set out in
G.S. 24-1 from the date of the entry of judgment. Your North Carolina Tax Refund or NC Education Lottery winnings may be
taken to pay for the cost of your court-appointed lawyer.
3. The information you provide may be verified, and your signature below will serve as a release permitting the interviewer to contact
your creditors, employers, family members, and others concerning your eligibility for a court-appointed lawyer. A false or dishonest
answer concerning your financial status could lead to prosecution for perjury. See G.S. 7A-456(a) (“A false material statement made
by a person under oath or affirmation in regard to the question of his indigency constitutes a Class I felony.”).
Under penalty of perjury, I declare that the information provided on this form is true and correct to the best of my knowledge, and that I
am financially unable to employ a lawyer to represent me. I now request the Court to assign a lawyer to represent me in this case.
I authorize the Court to contact my creditors, employers, or family members, any governmental agencies or any other entities listed
below concerning my eligibility for a court-appointed lawyer.
I further authorize my creditors, employers, or family members, any governmental agencies or any other entities listed below to release
financial information concerning my eligibility for a court-appointed lawyer upon request of the Court.
Governmental Agencies Or Other Entities Authorized To Be Contacted And/Or To Release Information
Date
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Signature
Signature Of Parent
Name Of Parent (type or print)
Deputy CSC
Assistant CSC
Clerk Of Superior Court
Magistrate
Date My Commission Expires
Notary
County Where Notarized
SEAL
NOTE:
If you are less than 18 years old, or if you are at least 18 years old but remain dependent on and live with a parent or guardian, state
name and address of parent, guardian or trustee below.
Name Of Parent/Guardian Or Trustee
Address
City, State, Zip
AOC-J-226, Side Two, Rev. 6/21
© 2021 Administrative Office of the Courts
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