STATE OF NORTH CAROLINA County Name Of Plaintiff File No. Film No. District Superior Court Division AFFIDAVIT AND REQUEST FOR HEARING IN CLAIM AND DELIVERY In The General Court Of Justice Name Of Defendant VERSUS G.S. 1-473; 475 The undersigned, being first duly sworn, says that the plaintiff has filed the above-captioned action to recover possession of personal property and now before judgment in the principal action claims the immediate delivery of the personal property described as follows until final judgment: The plaintiff owns the property, or is lawfully entitled to its possession by virtue of a special property interest therein, described as follows:(set forth special interest in property) The property is wrongfully detained by the defendant, and the cause of detention, according to affiant's knowledge, information and belief, is as follows: The property has not been taken for tax, assessment or fine, pursuant to a statute, or seized under an execution or attachment against the property, or if so seized, it is, by statute, exempt from such seizure. The actual value of the property is listed below. The undersigned requests the Clerk of Superior Court to issue a Notice of Hearing in this matter, and further requests that an order be entered enjoining the defendant from willfully disposing of the property in any manner, from removing or permitting the removal of the property from the State of North Carolina, or from causing or permitting willful destruction of the property. SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME $ Date Signature Of Person Authorized to Administer Oaths Deputy CSC Actual Value Of The Property Signature Of Affiant Name Of Affiant (Type Or Print) Assistant CSC Notary Date My Commission Expires Clerk Of Superior Court SEAL County Where Notarized Plaintiff Attorney Agent AOC-CV-200, Rev. 3/14 © 2014 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com