STATE OF NORTH CAROLINA

Name And Address Of AttorneyStreet Address

Defendant’s Telephone No.

Defendant’s Date Of Birth

I am self-represented.

I am homeless.

MOTION FOR RELIEF FROM FINES, FEES

AND OTHER MONETARY OBLIGATIONS,

AND ORDER ON MOTION

Name Of Defendant

File No.

STATE VERSUS

STATE OF NORTH CAROLINA

County

In The General Court Of Justice

District Superior Court Division

Title Of Position(s)

ABILITY TO PAY WORKSHEET

MONTHLY INCOME (money you make)

Name Of Employer(s)

I am unemployed.

a. Employment Income (after taxes)

Amount Per MonthDescription

Title Of Spouse’s Position(s)Name Of Spouse’s Employer(s)

My spouse is unemployed or I have no spouse.

b. Spouse’s Employment Income (after taxes), If Any $

e. Pension Payments

d. Rental Property Income

c. Investment Income

f. Child Support Payments Received By You

g. Gifts From Others

h. Other Income

(specify)

TOTAL MONTHLY INCOME

This income supports me and other people.

PUBLIC ASSISTANCE

a. TANF (Temporary Assistance for Needy Families)

Amount Per MonthDescription

d. SNAP/Food Stamps

c. Social Security Disability Insurance (SSDI)

b. Supplemental Security Income (SSI)

e. Veterans’ Benets

f. Other Public Assistance

(specify)

This public assistance supports me and other people.

TOTAL MONTHLY PUBLIC ASSISTANCE

(Over)

AOC-CR-415, New 9/20

MONTHLY EXPENSES (money you pay out)

a. Rent/Mortgage

Amount Per MonthDescription

d. Health Care/Medications (include medical debt repayment)

c. Utilities (power, water, heating, phone, internet, etc.)

b. Food/Groceries

e. Car/Transportation (include car insurance)

f. Entertainment

g. Child Care/Child Support Payments

h. Education (school tuition/fees)

(list school or program attended)

i. Taxes

j. Other expenses

(specify)

(Over - Defendant is to complete Certicate of Service on the next page)

(complete any or none of the checkbox options below)

I request to be given until

(enter date)

to pay any imposed monetary obligation.

request a payment plan requiring a total payment of no more than $ per month.

I request to complete community service in lieu of monetary payments.

I could pay $ today without substantially impacting my ability to pay other basic living expenses.

Under penalty of perjury, I declare that the information on this form is true and correct to the best of my knowledge.

Printed Name SignatureDate

ADDITIONAL INFORMATION

$TOTAL MONTHLY EXPENSES

a. Total Value of Bank and Other Investment Accounts Owned By You (specify types, but do not include

account numbers)

Based on the information presented above, I, the defendant named above,

(complete only one of the two checkbox options below)

request/move that the Court waive/remit/exempt the balance of ALL costs, fees, fines, and restitution.

request/move that the Court waive/remit/exempt the balance of the following specific monetary obligations:

(list)

REQUEST/MOTION

b. Total Value of Residence and Other Real Property Owned By You (specify)

c. Total Value of Jewelry and Other Personal Property Owned By You

(specify)

d. Total Value of Vehicles Owned By You (motor vehicles, watercraft, etc.) (specify)

e. Total Value of Debt You Owe to Others (specify) $

f. Other Information (Use the space below to provide any additional information about other circumstances the court should consider, such as your

ability to earn, a disability or illness, a recent term of incarceration, a change in work hours, or specic consequences.)

ORDER ON MOTION FOR RELIEF

The defendant’s request for relief from monetary obligation is:

Granted as indicated in the judgment or in the order below.

Denied.

I certify that a copy of this Motion was served by:

delivering a copy personally to the prosecutor.

depositing a copy, enclosed in a postpaid properly addressed envelope, in a post office or official depository under the exclusive

care and custody of the U.S. Postal Service directed to the prosecutor.

leaving a copy at the office of the prosecutor with an associate or employee.

Service accepted by prosecutor.

ORDER (INITIAL SENTENCING)

After notice and an opportunity to be heard and make objection by any directly affected government entity, the Court:

1. Waives the following costs:

Reduces the following costs to the amount indicated below:

In support of the waivers or reductions noted above, the Court nds just cause for that result in that the defendant:

Has no present ability to pay the monetary obligations indicated above.

Other:

For good cause and upon motion of the defendant, the defendant is exempted from

(select all that apply)

1. Probation supervision fees under G.S. 15A-1343(c1).

2. Electronic monitoring device fees under G.S. 15A-1343(c2).

3. Satellite-based monitoring fees under G.S. 14-208.45.

All costs,

excluding any

G.S. 7A-455.1

attorney

appointment

fee.

GCJF

Facilities Fee

Telecom/Data Fee

LEO Retirement Fee

LEO Training Fee

DNA Fee

Community Service Fee*

*NOTE:

There is ambiguity

as to whether this fee may be

waived.

Arrest/Process Fee

Chapter 20 Fee

Improper Equipment Fee

Impaired Driving Fee

Pretrial Jail Fee

Pretrial Release Services Fee

Blood Test (Parentage) Fee

Witness Fee

Lab/Hosp. Fee (Non-Digital Forensics)

Lab Fee (Digital Forensics)

Lab/Hospital Expert Witness Fee

Installment Setup Fee

Failure To Appear Fee

Failure To Comply Fee

State Crime Lab (Non-Digital Forensics) $

State Lab Expert Witness $

Local Lab (Non-Digital Forensics) $

Local Lab Expert Witness $

Private Hospital Toxicology $

Private Hospital Expert Witness $

(Over)

CERTIFICATE OF SERVICE

Date Served

Title

Signature Of Person Accepting Service

Name And Title Of Person With Whom Copy Left

Signature Of Person Serving

AOC-CR-415, Page Two, New 9/20

AOC-CR-415, Page Two, Side Two, New 9/20

CIVIL JUDGMENT

SIGNATURE OF JUDGE

ADDITIONAL ORDERS

1. License Revocation. The defendant has demonstrated to the Court under G.S. 20-24.1(b) that the failure to pay a penalty, fine, or

costs was not willful and that he or she is making a good faith effort to pay or that the penalty, fine, or costs should be remitted.

Failure to Appear. The Court strikes the Failure to Appear fee under G.S. 7A-304(a)(6) upon a showing that the defendant failed

to appear because an error or omission of a judicial ocial, prosecutor, or law enforcement ocer.

Other:

NOTE:

Civil judgments for attorney fees and the attorney appointment fee are ordered through the Trial Level Fee Application (AOC-CR-225) and

should not be entered again on this Order. Civil judgments for restitution are entered on the Restitution Worksheet (AOC-CR-611) or Restitution Update

Worksheet (AOC-CR-612) and should not be entered on this Order.

In response to the defendant’s default in the payment of costs, the Court orders a judgment for costs docketed as a lien on the

defendant’s real estate under G.S. 15A-1365. (NOTE:

No interest accrues on judgments for costs. G.S. 24-5.)

In response to the defendant’s default in the payment of nes, the Court orders a judgment for nes docketed as a lien on the

defendant’s real estate under G.S. 15A-1365. (NOTE:

Interest accrues on judgment for nes at 8 percent per year. G.S. 24-1.)

Name Of Presiding Judge (type or print) Signature Of Presiding JudgeDate

Remits the balance of the ne imposed in this case.

Reduces the ne imposed in this case to $ .

4. The defendant is allowed additional time to pay costs and/or fines as follows:

Restitution. After notice and an opportunity to be heard by the district attorney, the victim, the victim’s estate, and any other entity to

which restitution is owed, the court finds that remission of restitution is warranted and serves the interests of justice and:

Remits the balance of restitution in full.

Remits the balance of restitution in part as follows:

ORDER (LATER ACTION)

Upon petition of

the defendant, a prosecutor, and after notice and an opportunity to be heard and make objection by any

directly affected government entity, the Court:

1. Remits or reduces the following costs as indicated below:

Remits the

balance of

all costs

and fees,

excluding

any G.S.

7A-455.1

attorney

appointment

fee.

GCJF

Facilities Fee

Telecom/Data Fee

LEO Retirement Fee

LEO Training Fee

DNA Fee

Arrest/Process Fee

Chapter 20 Fee

Improper Equipment Fee

Impaired Driving Fee

EHA Fee

SBM Fee

Pretrial Jail Fee

Probation Jail Fee

Pretrial Release Fee

Lab/Hospital Fee

Lab Fee (Digital Forensics)

Lab/Hosp. Expert Witness Fee

Installment Setup Fee

Failure To Appear Fee

Failure To Comply Fee

Witness Fee

Probation Supervision Fee

Blood Test (Parentage) Fee

REMIT REMITDESCRIPTION DESCRIPTIONREDUCE TO REDUCE TO