Criminal Justice Debt Relief Program Application

Note to the applicant: The Criminal Justice Debt Programs provides criminal justice-related debt relief to low-income community members who are taking steps to successfully reintegrate into the community but whose ability to do so is hampered by debt from court fees and costs.

An advisory committee reviews applications monthly. You will be notified by email once the committee has made a decision on your application. Please note that all information submitted in this application becomes a public record.

In order to be considered eligible for relief, applicants:

Must live within Orange County, North Carolina
Must meet court indigency standards
Cannot be currently incarcerated
Must have outstanding criminal justice or traffic fees or costs
Must demonstrate that he or she is on the road to stability
Must have already pursued other avenues for debt relief (e.g., driver’s license restoration program)
Must demonstrate that assistance will have an immediate impact on his or her stability or successful reentry into the community

Relief will be considered for post-conviction court fees and costs, deferred prosecution court fees and costs, and NCDMV license restoration fees. Fines and restitution payments imposed as part of sentencing are not eligible for payment through the program.

If you have any questions about the application or program requirements, please contact us at debtprogram@townofchapelhill.org. Resident of Carrboro may contact the Carrboro Program Administer at 919-918-7397. All other residents should contact the 919-968-2806.

I acknowledge that all information submitted in this application becomes a public record and will be provided to the public upon request. The Town is not able to remove information from the public record once it has been submitted.*

I agree

Payments to the courts and to NCDMV must be made by the date ordered. You are solely responsible for the timeliness of your payments. There may be significant legal consequences for failure to pay monies as ordered, including, but not limited to, criminal liability, contempt of court, revocation of driver’s license, and other penalties.

With this in mind, please respond as follows:

I understand that there will be a delay between my application, approval of funds, and disbursement of funds if approved.*

YesNo

My application for funds under this program does not exempt me from my legal obligation to make payments to the courts or to NCDMV as ordered, and on time.*

YesNo

I will not hold the Town or its officials, or any member of the Criminal Justice Debt Program responsible for any consequences of my failure to pay, or for tardy payment.*

YesNo

What law enforcement agency serves the area that you reside?*

Chapel Hill Police DepartmentCarrboro Police DepartmentOrange County Sheriff's DepartmentHillsborough Police Department

Full Legal Name*

First NameMiddle NameLast Name

Do you have any other names that you use relevant to the charges you are seeking relief for?*

Date of Birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Alternate Phone Number

Area CodePhone Number

Email*

example@example.com

Please indicate how you identify*

Are you Hispanic or Latino?*

YesNoPrefer not to answer

Please indicate how you identify (select one or more)*

Have you completed an affidavit of indigency with the court?*

YesNoUnsure

What is your employment status?*

EmployedUnemployed

If you are employed, where are you working?*

How many hours do you work in a week?*

What is your hourly pay?*

Disability ($____ per Month)*

Food Stamps ($____ per Month)*

WIC ($____ per Month)*

Unemployment ($____ per Month)*

Temporary Assistance for Needy Families ($____ per Month)*

Medicaid and/or CHIP ($____ per Month)*

Federal Housing Assistance ($____ per Month)*

How many dependents do you have?*

Amount of Child Support received ($ ___ per Month)*

I am NOT receiving any child support.

Amount of Monthly Expenses ($ ___ per Month)*

Amount of Medical Debt *

Amount of Court and/or DMV Debt*

Amount of Credit Card Debt and/or other Consumer Debt*

Amount of Child Support Owed ($ ___ per month)*

Please include any other information that demonstrates your financial situation:*

I affirm, under the penalties for perjury, that the foregoing representations are true.*

YesNo

Has your North Carolina Driver License been suspended due to failure to pay court fees and costs?*

YesNoUnsure

Please explain the amount of court fees and costs you currently owe including the case number, county in which the money is owed, and exact amount of court fees and costs.

**COUNTY information is required to verify monies owed**

Are you currently on probation or parole?*

Please provide the name and phone number of your probation and/or parole officer.

Please provide your Drive License Number:

Please explain any fees you currently owe to North Carolina Division of Motor Vehicles (NCDMV):

If you must complete an alcohol assessment, please provide information on costs here:

How will funding from this program help you?*

Are you seeking services from other community agencies? If not, are you interested in being connected to resources?*

Have you tried other ways to get help for this outstanding debt such as from the Court or from the Driver's License Restoration Program?*

Have you applied to the Criminal Justice Debt Program previously?*

YesNo

If you have previously applied, please explain your reasoning for reapplying? *

How did you learn about our program?*

If you have application questions, please email debtprogram@townofchapelhill.org. You may also contact the Chapel Hill Police Crisis Unit at 919-968-2806 or Carrboro Police Department at 919-918-7354.

Please attach any supporting documentation that shows the costs and fees owed.

Browse Files

Criminal Justice Debt Program Application