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Request For State To Pay CAC And-Or GAL - New Hampshire

Request For State To Pay CAC And-Or GAL Form. This is a New Hampshire form and can be used in Other Probate Court Statewide .
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THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) REQUEST FOR STATE OF NEW HAMPSHIRE TO PAY COURT-APPOINTED COUNSEL AND/OR GUARDIAN AD LITEM (GAL) IMPORTANT: You must also complete the Financial Affidavit of Assets and Liabilities (NHJB-2017-P) and file it with this form. 1. What type of case is at issue? Involuntary Admission (RSA 135-C) Guardianship of Incapacitated Person (RSA 464-A) Termination of Parental Rights (RSA 170-C) Appeal to Supreme Court (RSA 567-A) Guardianship of Minor (RSA 463) Other 2. Name of person completing form if different than applicant: 3. Applicant's name: Date of birth 4. Legal residence of applicant: Street City/Town P. O. Box/Street City/Town State Telephone State Zip Code 5. Mailing address (If different from above): Zip Code 6. Marital status: (Check One) 7. Name of spouse: 8. Address of spouse: Single Married Divorced Separated Widowed 9. Living arrangement (Check one): w/Children w/Friend(s) Alone Other: w/Spouse w/Parent(s) I understand that I may be required to repay the State of New Hampshire for the services provided to me by court-appointed counsel or a GAL unless the court finds that I am or will be financially unable to pay. I understand that if at any time prior to the final disposition of my case, my financial condition improves, I must notify the court immediately. By submitting this Request and Financial Affidavit, I acknowledge that my financial condition may be investigated, my employment and credit verified, and a report made to the court. Date: Signature of applicant or person completing this form NHJB-2609-P (02/10/2010) (formerly 202) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: REQUEST FOR STATE OF NH TO PAY COURT-APPOINTED COUNSEL OR GAL AUTHORIZATION FOR THE RELEASE OF INFORMATION To Whom It May Concern: I hereby authorize the State of New Hampshire to obtain any and all information with regard to my employment, credit, and financial condition from governmental agencies, banks, creditors, or employers. Date Signature of applicant or person completing this form State of This instrument was acknowledged before me on , County of by Date Person signing above My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER Based on this Request and the Financial Affidavit of Assets and Liabilities, the applicant is: Ineligible to have the State of NH pay for court appointed counsel or guardian ad litem fees and expenses. Eligible to have the State of NH pay for court appointed counsel or guardian ad litem fees and expenses. Eligible to have the State of NH pay for court appointed counsel or guardian ad litem fees and expenses, but liable for partial or full repayment to the State of NH. The amount due will be determined once the Statement of Services has been filed by the Attorney for the Ward or the GAL and approved by the court. An Order for Repayment will be issued at that time. Date Judge NHJB-2609-P (02/10/2010) (formerly 202) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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