Fillable Divorce Packet *This packet should be printed double-sided.

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*This packet should be printed double-sided.
Divorce Packet
Provided by:
Legal Aid of North Carolina, Inc.
This packet is designed for use with a video that provides step-by-step
instructions on how to file for divorce in North Carolina without a lawyer.
The video is presented on a regular basis at Legal Aid of North Carolina
offices and at certain other locations. Following the video, an attorney is
available through the webinar to answer general questions. To attend a
presentation, contact your nearest Legal Aid of North Carolina office.
USE THIS PACKET ONLY IF:
You or your spouse have lived in North Carolina for at least
the last 6 months
You have been separated from your spouse for at least 12
months
You are not interested in receiving alimony or spousal support
You are not interested in having your property divided
between you and your spouse
Instructions/“Cheat Sheets”
STEP 1 – WHAT YOU FILE
(Courthouse clerk-filing fee in June 2015: $225.00 plus additional $10.00 if resuming
maiden name or pre-marriage surname. NOTE: Filing fees are subject to change.)
1. Complaint (3 Copies)
2. Court Action Cover Sheet (1 copy)
3. Civil Summons (1 white and 2 yellow)
White summons must end up in court file.
4. Servicemembers Civil Relief Act Affidavit (1 copy)
(Optional)
-Petition to Sue as an Indigent (AOC-G-106) 1 copy
-Affidavit of Indigency (AOC-CV-226) 1 copy
STEP 2 – SERVING THE DEFENDANT (must be served by 1 of the following
methods)
DEFENDANT MUST GET THE FOLLOWING: 1 Complaint, 1 Summons
THERE MUST BE PROOF IN COURT FILE THAT DEFENDANT WAS SERVED.
1. Sheriff – deputy who serves will place white summons in court file ($30.00 fee)
2. Certified Mail – You fill out the affidavit of service by mail (in front of a notary)
-must be placed in court file along with white summons
3. Accept Service – Defendant fills out acceptance of service (in front of a notary)
-must be placed in court file along with white summons
4. Publication by Newspaper
STEP 3 – GETTING THE ORDER SIGNED – 2 OPTIONS
Option 1 – CLERK GRANTING THE DIVORCE
Must wait at least 30 days from the date DEFENDANT was served.
1. On day 31 or after, go to the clerk’s office and leave the Judgment for Absolute Divorce
Before the Clerk (AOC-CV-710) (3 copies) and Certificate of Absolute Divorce or
Annulment (AOC-CV-711) (3 copies).
2. Go to nccourts.org/ Click on Forms, put in form number, and fill out online.
3. Clerk will review the court file and sign the Order.
Option 2 – JUDGE GRANTING THE DIVORCE
Hearing must be at least 30 days from date DEFENDANT was served.
Our presentation explains the process of getting the Order signed by the clerk of court. In some
instances, you may need to have your order signed by a judge. You should check with your local
clerk of court to find out the process in your county.
STATE OF NORTH CAROLINA
IN THE GENERAL COURT OF JUSTICE
COUNTY OF __________________
DISTRICT COURT DIVISION
File No.
_____________________________
)
Plaintiff,
)
)
vs.
) COMPLAINT FOR ABSOLUTE DIVORCE
)
_____________________________
)
Defendant.
)
______________________________________________________________________________
The Plaintiff, complaining of the Defendant, alleges:
1. The Plaintiff is a citizen and resident of ____________________County, North Carolina.
2. The Defendant is a citizen and resident of___________________County, North Carolina.
3. (check one or both) The Plaintiff ( ) and/or the Defendant ( ) has been a citizen and
resident of North Carolina for at least six (6) months immediately preceding the
institution of this action.
4. The Plaintiff and Defendant were married on or about______________________(date of
marriage) and thereafter they lived together as husband and wife until on or about
____________________________ (date of separation) at which time they separated.
5. Since the date of separation stated above, the Plaintiff and Defendant have lived
continuously separate and apart from each other, and at no time have they resumed the
marital relation that formerly existed between them.
6. At the time of the separation, the Plaintiff intended the separation to be permanent.
7. There were: (check one) ( ) No children born of the marriage.
( ) ___ (number) minor child(ren) born to the
marriage of the parties, namely:
Full Name of Child
Date of Birth
Date of Birth
Full Name of Child
Date of Birth
Date of Birth
8. The minor child(ren) reside with__________________________________(name of
party)
at______________________________________________________________(address).
9. The Plaintiff, whether husband or wife, acknowledges that he/she is not demanding of
Defendant alimony or equitable distribution and he/she acknowledges that unless such
claims are asserted by him/her before Judgment is entered on this Complaint, he/she is
forever waiving and discharging any claim against Defendant for alimony and/or
equitable distribution by obtaining an absolute divorce.
10. ( ) (check if applicable) The Plaintiff desires to resume the use of his/her former
name,_____________________________________________________(print name).
WHEREFORE, the Plaintiff prays the court for relief as follows:
1. That the bonds of matrimony which have existed between the parties be dissolved and that
he/she be granted an absolute divorce from the Defendant.
2. ( ) (check if applicable) The Plaintiff desires to resume the use of his/her former
name,_____________________________________________________(print name).
This the ______ day of ______________, 20_____.
_______________________________________
(Plaintiff’s full name - SIGNATURE)
_______________________________________
(Address of Plaintiff)
_______________________________________
(City, State, Zip Code of Plaintiff)
VERIFICATION
(Must be signed before a Notary Public)
I, _____________________________________________________ (print Plaintiff’s name),
being first duly sworn, depose and say that I am the Plaintiff herein, that I have read the forgoing
Complaint for Absolute Divorce and know the statements therein to be true of my own
personal knowledge, except as to those matters alleged upon information and belief, and as to
those matters, I believe them to be true.
This the ______ day of ___________________________ 20____
_____________________________________________
Plaintiff’s full name – SIGNATURE
Sworn to and Subscribed before me this the _______ day of
_____________________________________________________.
_____________________________________________________
Notary Public
My Commission expires:_________________________________
STATE OF NORTH CAROLINA
File No.
Name And Address Of Plaintiff 1
Amended Answer/Reply (AMND-Response)
Amended Complaint (AMND)
Answer/Reply (ANSW-Response)
Complaint (COMP)
Confession Of Judgment (CNFJ)
Contempt (CNTP)
Continue (CNTN)
Compel (CMPL)
Counterclaim vs. (CTCL) Assess Counterclaim Costs
Extend Time For An Answer (MEOT-Response)
Modification Of Alimony (MALI)
Modification Of Custody (MCUS)
Modification Of Support in non-IV-D cases (MSUP)
Modification Of Visitation (MVIS)
Rule 12 Motion In Lieu Of Answer (MDLA)
Sanctions (SANC)
Show Cause (SHOW)
Transfer (TRFR)
Vacate/Modify Judgment or Order (VCMD)
Other (OTHR):
Jury Demanded In Pleading? No Yes
Summons Submitted
DOMESTIC
CIVIL ACTION COVER SHEET
All filings in civil actions shall include as the first page of the filing a cover sheet summarizing the critical elements of the filing in a format prescribed by the
Administrative Office of the Courts and the Clerk of Superior Court shall require a party to refile a filing which does not include the required cover sheet. For
subsequent filings in civil actions, the filing party must include a Domestic (AOC-CV-750), Motions (AOC-CV-752), or Court Action (AOC-CV-753) cover sheet.
Alimony (ALIM)
Annulment (ANUL)
Child Support (CSUP)
Custody (CUST)
Divorce (DIVR)
Divorce From Bed And Board (DIVB)
Domestic Violence (DOME)
Equitable Distribution (EQUD)
Medical Coverage (MEDC)
Paternity (PATR)
Possession Of Personal Property (POPP)
Post Separation Support (PSSU)
Reimbursement For Public Assistance (RPPA)
Visitation (VIST)
Other: (specify and list separately)
Telephone No. Cellular Telephone No.
Name Of Firm
NC Attorney Ba
r
No.
Change of Address
Initial Appearance in Case
Name And Address Of Attorney Or Party, If Not Represented (complete for initial
appearance or change of address)
FAX No.
Attorney E-Mail Address
AOC-CV-750, Rev. 1/14
© 2014 Administrative Office of the Courts
In The General Court Of Justice
District Court Division
County
Rule 5(b), Rules of Practice For Superior and District Courts
INITIAL FILING SUBSEQUENT FILING
Name And Address Of Plaintiff 2
Name Of Defendant 1
Yes No
Name Of Defendant 2
Summons Submitted
Yes No
Counsel for
All Plaintiffs
Only
(List party(ies) represented)
All Defendants
(check all that apply)
CLAIMS FOR RELIEFTYPE OF PLEADING
(check all that apply)
Date
Signature Of Attorney/Party
NOTE:
VERSUS
STATE OF NORTH CAROLINA
County
File No.
Name Of Plaintiff
City, State, Zip
Address
Name Of Defendant(s)
Name And Address Of Defendant 1 Name And Address Of Defendant 2
Date(s) Subsequent Summons(es) Issued
Date Original Summons Issued
In The General Court Of Justice
District Superior Court Division
CIVIL SUMMONS
ALIAS AND PLURIES SUMMONS (ASSESS FEE)
G.S. 1A-1, Rules 3 and 4
To Each Of The Defendant(s) Named Below:
VERSUS
IMPORTANT! You have been sued! These papers are legal documents, DO NOT throw these papers out!
You have to respond within 30 days. You may want to talk with a lawyer about your case as soon as
possible, and, if needed, speak with someone who reads English and can translate these papers!
¡IMPORTANTE! ¡Se ha entablado un proceso civil en su contra! Estos papeles son documentos legales.
¡NO TIRE estos papeles!
Tiene que contestar a más tardar en 30 días. ¡Puede querer consultar con un abogado lo antes posible
acerca de su caso y, de ser necesario, hablar con alguien que lea inglés y que pueda traducir estos
documentos!
A Civil Action Has Been Commenced Against You!
You are notied to appear and answer the complaint of the plaintiff as follows:
1. Serve a copy of your written answer to the complaint upon the plaintiff or plaintiff’s attorney within thirty (30) days after you have been
served. You may serve your answer by delivering a copy to the plaintiff or by mailing it to the plaintiff’s last known address, and
2. File the original of the written answer with the Clerk of Superior Court of the county named above.
If you fail to answer the complaint, the plaintiff will apply to the Court for the relief demanded in the complaint.
NOTE TO PARTIES:
Many counties have MANDATORY ARBITRATION programs in which most cases where the amount in controversy is $25,000 or
less are heard by an arbitrator before a trial. The parties will be notified if this case is assigned for mandatory arbitration, and, if
so, what procedure is to be followed.
(Over)
Name And Address Of Plaintiff’s Attorney (if none, Address Of Plaintiff) Date Issued
Date Of Endorsement
Signature
Signature
Time
Time
Deputy CSC
Assistant CSC
Clerk Of Superior Court
Deputy CSC
Assistant CSC
Clerk Of Superior Court
ENDORSEMENT (ASSESS FEE)
This Summons was originally issued on the date indicated
above and returned not served. At the request of the plaintiff,
the time within which this Summons must be served is
extended sixty (60) days.
AM PM
AM PM
AOC-CV-100, Rev. 4/18
© 2018 Administrative Ofce of the Courts
RETURN OF SERVICE
I certify that this Summons and a copy of the complaint were received and served as follows:
DEFENDANT 1
Date Served Name Of DefendantTime Served
By delivering to the defendant named above a copy of the summons and complaint.
By leaving a copy of the summons and complaint at the dwelling house or usual place of abode of the defendant named above with a
person of suitable age and discretion then residing therein.
As the defendant is a corporation, service was effected by delivering a copy of the summons and complaint to the person named
below.
Other manner of service
(specify)
Defendant WAS NOT served for the following reason:
Name And Address Of Person With Whom Copies Left (if corporation, give title of person copies left with)
By delivering to the defendant named above a copy of the summons and complaint.
By leaving a copy of the summons and complaint at the dwelling house or usual place of abode of the defendant named above with a
person of suitable age and discretion then residing therein.
As the defendant is a corporation, service was effected by delivering a copy of the summons and complaint to the person named
below.
Other manner of service
(specify)
Defendant WAS NOT served for the following reason:
Name And Address Of Person With Whom Copies Left (if corporation, give title of person copies left with)
AM PM
DEFENDANT 2
Date Served Name Of DefendantTime Served
AM PM
Service Fee Paid
Date Received
Date Of Return County Of Sheriff
Name Of Sheriff (type or print)
Signature Of Deputy Sheriff Making Return
$
AOC-CV-100, Side Two, Rev. 4/18
© 2018 Administrative Ofce of the Courts
AFFIDAVIT
VERSUS
Name Of Plaintiff
Name Of Defendant
PETITION TO PROCEED
AS AN INDIGENT
G.S. 1-110; 7A-228
(check one of the four boxes below)
Petition To Assert Claims - As a party in the above entitled action, I affirm that I am financially unable to advance the required costs for the
prosecution of the claims I have asserted. Therefore, I now petition the Court for an order allowing me to assert my claims as an indigent.
I am an inmate in the custody of the Division of Adult Correction and Juvenile Justice.
(
NOTE TO CLERK: If this block is checked, this Petition must be submitted to a Superior Court Judge for disposition provided on the reverse.)
Petition To File Motions - As a party in the above entitled action, I affirm that I am financially unable to advance the required costs to
file a notice of hearing on a motion. Therefore, I now petition the Court for an order allowing me to file my motion as an indigent.
Petition To Appeal - As the individual appellant in the above entitled small claims action, I affirm that I am financially unable to pay
the cost for the appeal of this action from small claims to district court. Therefore, I now petition the Court for an order allowing me to
appeal this action to district court as an indigent.
Petition To File Expunction Petition - As the petitioner in the above entitled action, I affirm that I am financially unable to advance
the required costs to file an expunction petition. Therefore, I now petition the Court for an order allowing me to file my expunction
petition as an indigent.
(check one or more of the boxes below as applicable)
I am presently a recipient of
Supplemental Nutrition Assistance Program (SNAP/food stamps). Temporary Assistance for Needy Families (TANF).
Supplemental Security Income (SSI).
I am represented by a legal services organization that has as its primary purpose the furnishing of legal services to indigent persons, or I
am represented by private counsel working on behalf of such a legal services organization. (Attach a letter from your legal services attorney
or have your attorney sign the certicate below.)
Although I am not a recipient of SNAP/food stamps, TANF, or SSI, nor am I represented by legal services, I am nancially unable to
advance the costs of ling this action or appeal.
File No.
STATE OF NORTH CAROLINA
County
In The General Court Of Justice
District Superior Court Division
Name And Address Of Petitioner (type or print)
Date Commission Expires
Title Of Person Authorized To Administer Oaths
Date
Date Signature Of PetitionerSignature
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
CERTIFICATE OF LEGAL SERVICES/PRO BONO REPRESENTATION
I certify that the above named petitioner is represented by a legal services organization that has as its primary purpose the furnishing of
legal services to indigent persons or is represented by private counsel working on behalf of or under the auspices of such legal services
organization.
Date Signature
Name And Address (type or print)
ORDER
Based on the Affidavit appearing above, it is ORDERED that:
the petitioner is authorized to assert claims, to appeal, or file notices of hearing or petitions in this action as an indigent.
the petition is denied.
NOTE TO CLERK: If the petitioner is NOT a recipient of SNAP/food stamps, TANF, SSI or is NOT represented by legal services or a private attorney on
behalf of legal services, you may ask for additional financial information to determine whether the petitioner is unable to pay the costs.
SignatureDate
Assistant CSC
Clerk Of Superior Court
Judge Magistrate (for appeal only)
SEAL
AOC-G-106, Rev. 2/18, © 2018 Administrative Ofce of the Courts
(Over)
ORDER - DACJJ INMATES
CERTIFICATION
The undersigned superior court judge of this district nds that the petitioner is an inmate in the custody of the Division of Adult Correction
and Juvenile Justice and that the complaint
is not frivolous.
is frivolous.
It is ORDERED that
the petitioner is authorized to sue in this action as an indigent.
the petitioner is not authorized to sue as an indigent.
the action is dismissed.
I certify that this Petition has been served on the party named by depositing a copy in a post-paid properly addressed envelope in a post
ofce or ofcial depository under the exclusive care and custody of the United States Postal Service.
Date Name Of Superior Court Judge (type or print) Signature Of Superior Court Judge
Date Signature
Deputy CSC
Assistant CSC
Clerk Of Superior Court
NOTE: G.S. 1-110(b) provides: “The clerk of superior court shall serve a copy of the order of dismissal upon the prison inmate.”
AOC-G-106, Side Two, Rev. 2/18
© 2018 Administrative Ofce of the Courts
District 11
JLL/kwj 5/2015
STATE OF NORTH CAROLINA
______________________ County
File No.
In The General Court Of Justice
District Court Division
Name of Plaintiff
AFFIDAVIT
Servicemembers Civil Relief Act
50 U.S.C. App. §§501-597b
VERSUS
Name of Defendant
AFFIDAVIT
I, ______________________________, being duly sworn, deposes and says:
(print your name)
1. The Plaintiff Defendant ____________________________, is in military service. is not in
military service.
(print name of non-moving party)
The following facts support the statement above about the non-moving party’s military service: (State how
you know the non-moving party is or is not in the military. Be specific.)
______________________________________________________________________________________
______________________________________________________________________________________
2. The affiant is unable to determine whether or not the non-moving party is in military service.
Signature Of Affiant
Name of Affiant
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Signature Of Person Authorized To Administer Oaths
Deputy CSC Assistant CSC Clerk Of Superior Court Notary
Date Commission Expires
SEAL
County Where Notarized
FOR COURT USE ONLY:
ORDER OF APPOINTMENT OF COUNSEL
The Court finds that appointment of counsel is required pursuant to 50 U.S.C. App. § 521 or 522 and therefore,
the Court appoints counsel named below to represent the absent servicemember named above:
Name of Attorney
Name, Street Address, PO Box, City, State And Zip Code Of Attorney
Telephone No.
STAY OF PROCEEDINGS
The Court finds that a stay of proceedings is required pursuant to 50 U.S.C. App. § 521 and, therefore, such a
stay, for a minimum period of 90 days, is ordered.
Date
Signature of Judge
Next Hearing Date and Time
Name of Judge (Type or Print)
Information About Servicemembers Civil Relief Act Afdavits
1. Plaintiff to le afdavit
In any civil action or proceeding, including any child custody proceeding, in which the defendant
does not make an appearance, the court, before entering judgment for the plaintiff, shall require the
plaintiff to le with the court an afdavit—
(A) stating whether or not the defendant is in military service and showing necessary facts to
support the afdavit; or
(B) if the plaintiff is unable to determine whether or not the defendant is in military service,
stating that the plaintiff is unable to determine whether or not the defendant is in military
service.
50 U.S.C. 3931(b)(1).
2. Appointment of attorney to represent defendant in military service
If in a civil action or proceeding in which the defendant does not make an appearance it appears
that the defendant is in military service, the court may not enter a judgment until after the court
appoints an attorney to represent the defendant. If an attorney appointed to represent a service
member cannot locate the service member, actions by the attorney in the case shall not waive any
defense of the service member or otherwise bind the service member. 50 U.S.C. 3931(b)(2).
State funds are not available to pay attorneys appointed pursuant to the Servicemembers Civil
Relief Act. To comply with the federal Violence Against Women Act and in consideration of
G.S. 50B-2(a), 50C-2(b), and 50D-2(b), plaintiffs in Chapter 50B, Chapter 50C, and Chapter
50D proceedings should not be required to pay the costs of attorneys appointed pursuant to the
Servicemembers Civil Relief Act. Plaintiffs in other types of actions and proceedings may be
required to pay the costs of attorneys appointed pursuant to the Servicemembers Civil Relief Act.
The allowance or disallowance of the ordering of costs will require a case-specic analysis.
3. Defendant’s military status not ascertained by afdavit
If based upon the afdavits led in such an action, the court is unable to determine whether the
defendant is in military service, the court, before entering judgment, may require the plaintiff to le
a bond in an amount approved by the court. If the defendant is later found to be in military service,
the bond shall be available to indemnify the defendant against any loss or damage the defendant
may suffer by reason of any judgment for the plaintiff against the defendant, should the judgment be
set aside in whole or in part. The bond shall remain in effect until expiration of the time for appeal
and setting aside of a judgment under applicable Federal or State law or regulation or under any
applicable ordinance of a political subdivision of a State. The court may issue such orders or enter
such judgments as the court determines necessary to protect the rights of the defendant under this
Act. 50 U.S.C. 3931(b)(3).
4. Satisfaction of requirement for afdavit
The requirement for an afdavit above may be satised by a statement, declaration, verication, or
certicate, in writing, subscribed and certied or declared to be true under penalty of perjury.
50 U.S.C. 3931(b)(4). The presiding judicial ofcial will determine whether the submitted afdavit is
sufcient.
5. Penalty for making or using false afdavit
A person who makes or uses an afdavit permitted under 50 U.S.C. 3931(b) (or a statement,
declaration, verication, or certicate as authorized under 50 U.S.C. 3931(b)(4)) knowing it to be
false, shall be ned as provided in title 18, United States Code, or imprisoned for not more than one
year, or both. 50 U.S.C. 3931(c).
AOC-G-250, Side Two, Rev. 2/18
© 2018 Administrative Ofce of the Courts
Total Monthly Income
STATE OF NORTH CAROLINA
File No.
$ $
$
Car Expenses
(gas, insurance, etc.)
Shelter
Other:
(specify)
Food (including Food Stamps)
Utilities
(power, water, heating, phone,
cable, etc.)
Health Care
Installment Payments
Support Payments
$
$
Total Monthly Expenses
$
Full Social Security No.
(Fair Market Value)
(Fair Market Value)
$
$
$
(Fair Market Value)
(Balance Due)
Total Assets And Liabilities
Money Owed To Or Held For Applicant
(Over)
Number Of Dependents
Personal Property
Real Estate
Motor Vehicles
(List Make, Model, Year)
Cash On Hand And In Bank Accounts
(List Name Of Bank & Account No.)
DESCRIPTION OF ASSETS AND LIABILITIES
(Balance Due)
(Balance Due)
ASSETS
(things you own)
LIABILITIES
(amounts you owe)
$
$
$
$
Vehicle Other
$
$
Name And Address Of Applicant's Employer
(If not employed, state reason; if self-employed, state trade)
Employment - Applicant
Other Income (Welfare, Food Stamps,
S/S, Pensions, etc.)
Employment - Spouse
Buying
Renting
Name And Address Of Spouse's Employer
$
$
$
$
$
$
$
MONTHLY EXPENSES (money you pay out)
Last Income Tax Filed 20
Other Debts
Other
Bond Type
AOC-CV-226, Rev. 10/13
© 2013 Administrative Office of the Courts
By Whom Posted
$
$
$
Has No Social Security No.
-
-
Plaintiff
Defendant
MONTHLY INCOME (money you make)
Refund Owe
$
$
Amount
NOTE: Read the notice on the reverse side before completing this form.
(TYPE OR PRINT IN BLACK INK)
County
Name Of Applicant
CIVIL AFFIDAVIT OF INDIGENCY
G.S. 7A-450 et seq.
Date Of Birth
Telephone Number Of Applicant
Full Permanent Mailing Address Of Applicant (If Different Than Above)
$
$
In The General Court Of Justice
District Superior Court Division
Street Number And Street Name, Including Apartment Or Unit Number If Applicable
City, State And Zip Code
County Where Notarized
Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate
Notary
SEAL
SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date
Plaintiff
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 an
indigency designation. 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.").
3.
Signature
Signature Of Applicant
Date
Name Of Applicant (Type Or Print)
Date My Commission Expires
Governmental Agencies Or Other Entities Authorized To Be Contacted And/Or To Release Information
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 pay all or part of the arbitration fees prior to the arbitration. I now request that I be
designated indigent or partially indigent. I authorize the Court to contact my creditors, employers, or family members, any
government agencies or any other entities listed below concerning my eligibility for such designation.
AOC-CV-226, Side Two, Rev. 10/13
© 2013 Administrative Office of the Courts
NOTICE TO PERSONS REQUESTING INDIGENCY OR PARTIAL INDIGENCY DESIGNATION
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. Do not ask the interviewer for any advice or opinion concerning your case.
1.
A designation of indigency relieves your obligation to pay all of the arbitration fee. A
designation of partial indigency requires you to pay your appropriate percentage of your
pro rata share of the arbitration fee prior to arbitration. Failure to pay the arbitration fee will
result in the entry of 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
and/or North Carolina Lottery winnings may be taken.
2.
I further authorize my creditors, employers, or family members, any governmental agencies or any other entities listed
below to release financial in
formation concerning my eligibility for such designation upon request of the Court.
Defendant
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Completed 19 January 2021

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