File No. STATE OF NORTH CAROLINA County SEARCH WARRANT FOR BLOOD OR URINE IN DWI CASES Name Date Issued Name Of Applicant Name Of Additional Affiant Name Of Additional Affiant In The General Court Of Justice District Court Division To any officer with authority and jurisdiction to conduct the search authorized by this Search Warrant: I, the undersigned, find that there is probable cause to believe that the property and person described in the application on the reverse side and on the attached sheets and related to the commission of a crime is located as described in the application. IN THE MATTER OF Time Issued AM PM You are commanded to take the person named in the application to a physician, registered nurse, emergency medical technician or other qualified person to obtain sample(s) of blood and/or urine described in the application from the person named in the application. You are to seize the sample(s), have the sample(s) tested for one or more impairing substances and keep the unconsumed sample(s) subject to court order and process the person according to law. You are directed to execute this Search Warrant within forty-eight (48) hours from the time indicated on this Warrant and make due return to the Clerk of the issuing court. This Search Warrant is issued upon information furnished under oath or affirmation by the person(s) shown. RETURN OF SERVICE I certify that this Search Warrant was received and executed as follows: Date Received Date Executed Time Received Time Executed I made a search of AM AM PM PM Date Name (Type Or Print) Signature I seized the items listed on the attached inventory. I did not seize any items. This Warrant WAS NOT executed within forty-eight (48) hours of the date and time of issuance and I hereby return it not executed. Name Of Officer Making Return (Type Or Print) Signature Of Officer Making Return Deputy CSC Assistant CSC CSC Magistrate District Court Judge Superior Court Judge as commmanded. This Search Warrant was delivered to me on the date and at the time shown below when the Office of the Clerk of Superior Court is closed for the transaction of business. By signing below, I certify that I will deliver this Search Warrant to the Office of the Clerk of Superior Court as soon as possible on the Clerk's next business day. Date Time This Search Warrant was returned to the undersigned clerk on the date and time shown below. Incident Number Date Time AM PM Name Of Magistrate (Type Or Print) Signature Of Magistrate Department Or Agency Of Officer AM PM Name Of Clerk (Type Or Print) Signature Of Clerk AOC-CR-155, Rev. 12/15 © 2015 Administrative Office of the Courts (Over) Dep. CSC Asst. CSC CSC American LegalNet, Inc. www.FormsWorkFlow.com (Attach additional sheets if necessary.) Rank Name Of Law Enforcement Officer (Applicant) Name Of Individual To Be Searched Location Of Individual To Be Searched APPLICATION FOR SEARCH WARRANT FOR BODILY FLUIDS N.C. State Highway Patrol Race Crime(s) Charged DWI. G.S. 20-138.1. Habitual DWI. G.S. 20-138.5. I, the law enforcement officer named above, being duly sworn, request that the Court issue a warrant to search the person of the individual named above, who may be found at the location described above, and to seize sample(s) of the above-specified bodily fluid(s) of that individual. I swear to the following facts to establish probable cause for the issuance of a search warrant. I am a sworn law enforcement officer of the above-named agency. As such, I am empowered to search for and seize evidence described in N.C. General Statutes Chapter 14, Criminal Law, Chapter 20, Motor Vehicle Law, and Chapter 90, Controlled Substances. I have received training in the detection and apprehension of impaired drivers and the investigation of motor vehicle collisions. I have been a sworn law enforcement officer for over years and during that time I have investigated over incidents of offenses related to impaired driving. 1. I rely on the facts stated in the following report(s), of which a copy or copies is/are attached and incorporated by reference: (Attach a copy of the report(s) checked below if Commercial DWI. G.S. 20-138.2. Death By Vehicle. G.S. 20-141.4. Other (specify) Blood Urine Male Female Fluid To Be Seized Police/Sheriff The above-named c. the time and place individual admitted to me operating the described vehicle at indicated. d. On or about the date stated above, at I detected a strong moderate faint odor AMalcoholPM of coming from the breath of the above-named person: the scene. at the following hospital . at other location at the following behaviors of the individual named above, which . I observed evidence impairment of the person's mental and/or physical faculties as follows: The above-named individual e. described vehicle he/she: stated to me that before or while operating the had consumed alcohol. consuming alcohol. was consumed controlled substance, to wit: had had consumed other impairing substance, to wit: f. The above-named individual refused to submit to a chemical analysis. g. I observed the following facts: . . h. Other reliable persons stated to me the following facts: and Report (AOC-CVR-1A/DHHS 3907). AffidavitWhileRevocationReport Form/Alcohol Influence Report Form. Driving Impaired The day , 2. at following facts establish on or about the namedofabove was operating a , AM PM, the individual ( commercial motor) vehicle, to wit: The above-named individual 3. involving impaired driving. has previously been convicted of one or more offenses on a County highway/street public vehicular area in Based on all the foregoing, and on my training in detecting impaired driving violations and at or near the city/town of in violation of available and if either contains relevant facts.) (Note: Name officer or witness(es) and list facts related to impairment, vehicle operation, etc.) (type, make and year) the statute(s) specified above: (check all that apply) place stated above: a. At the time andthe above-named individual operating the above-described I observed vehicle. observed Imanner: the above-described vehicle being operated in the following On or about date above, at b. responded tothereportstatedvehicle crash and, after arriving atAM scene, I I the PM, a of a ascertained that the above-named individual was operating the described vehicle at the time and place stated from the following facts: my experience as a law enforcement officer, I have formed an opinion satisfactory to myself that the abov