Free Court-Funded Invoice Parenting Plan Home Study, SCA-FC-502 - West Virginia

COURT-FUNDED INVOICE PARENTING PLAN HOME STUDY
EVALUATOR PAYMENT INFORMATION
Name of evaluator: _________________________________________________ Make check payable to:_______________________________________________ Address for remittance:_______________________________________________ ________________________________________________

FUND 1759

Return ORIGINAL to: Pepper Flenner WV Supreme Court 1900 Kanawha Boulevard East Building. 1, Room E-100 Charleston, WV 25305

Phone:___________________ Fax: ___________________ E-mail address:_________________________________ Payee's Social Security Number or F.E.I.N. (whichever applies):_________________________________________ Highest Education completed: " Bachelors Degree Field :

" Masters Degree " Social Work

" Doctoral Degree " Law " Other

" Psychology

" Psychiatry

" Counseling

HOURLY RATE IS $45.00 FOR OUT-OF COURT AND $65.00 FOR IN-COURT, NOT EXCEEDING A TOTAL OF $750.00
HOURS SPENT ON THE CASE (MUST BE ROUNDED TO TENTHS OF AN HOUR)

TASK
IN-COURT OUT-OF-COURT TOTALS

HOURS SPENT

RATE OF PAY
65.00 45.00 -

TOTAL

BILLING INFORMATION:
Please pay the Parenting Plan Home Study Evaluator listed above $______________ for performing an evaluation on Case # _______________ from ________________________County
Amount of payment may not exceed $750.00 per case Evaluators`s Signature ______________________________________________________________ Date ________
* MUST be signed by parenting plan evaluator in blue ink

Please attach a copy of the Judge's Order Approving Payment and a signed Independent Contractor's Agreement

Approved by Supreme Court: _________________________________________________________ SCA­FC-502 (6/03)

Date:_________________ Page 1 of 2

Evaluator's Name: ____________________________________________________________________

PARENT CONTACT INFORMATION
(1)

Case # __________________________

Name: __________________________________________ Address: ____________________________________ ____________________________________ Daytime Phone: ___________________________ Evening Phone: ______________________

(2)

Name: __________________________________________ Address: ________________________________________ ________________________________________ Daytime Phone: ___________________________ Evening Phone: _____________________

SESSION INFORMATION:
County(ies) Conducted in: ________________________________________________________________ Did either parent fail to attend the meeting? If yes which parent(s) did not attend?

" Yes

" No " Father " Both

" Mother

Had the parties reached an agreement before the scheduled evaluation?

" Yes, full agreement
Mother: Father: Child(ren):

" Yes, partial agreement

" No agreements reached

Whom did you interview? (Please list the name and the number of hours spent with each person) _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Other: Other: Other: ________________________________ _________________________________ ________________________________ Number of hours _____________ Number of hours _____________ Number of hours _____________ Number of hours _____________ Number of hours _____________ Number of hours _____________ Number of hours _____________ Number of hours _____________ Number of hours _____________

SCA­FC-502 (6/03)

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