(TYPE OR PRINT IN BLACK INK) AFFIDAVIT TO OBTAIN STATE OF NORTH CAROLINA ADMINISTRATIVE INSPECTION In The General Court Of Justice WARRANT FOR County PERIODIC INSPECTION I, , being (name and position) duly sworn and examined under oath, state under oath that there is a program of inspection authorized by (identify statute or regulation authorizing inspection) which naturally includes the property owned or possessed by (name owner or possessor) and described as follows: (precisely describe the property to be inspected) The program of inspection referred to covers the area (indicate town, county, or portion thereof, or other specific territory covered by inspection program)and is being conducted for the purpose of checking or revealing the following: (state conditions, objects, activities, or circumstances covered by inspection program) This inspection program is a legal function of (name agency) and is under the supervision of (identify person responsible for inspection program) Signature Of Applicant Name Of Applicant (Type Or Print) SWORN AND SUBSCRIBED TO BEFORE ME: Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate District Court Judge Superior Court JudgeIMPORTANT: Attach the Affidavit to the WARRANT if not on reverse side. AOC-CR-914M, Rev. 7/2000 (Over) 2000 Administrative Office of the Courts >>>> 2 File No. (TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA In The General Court Of Justice ADMINISTRATIVE INSPECTION County WARRANT FOR PERIODIC INSPECTION G.S. 15-27.2 TO ANY LAWFUL OFFICIAL EMPOWERED TO CONDUCT THE INSPECTION AUTHORIZED BY THIS WARRANT: The applicant named on the accompanying affidavit, being duly sworn, has stated to me that the property described in that affidavit is to be inspected as part of a legally authorized program of inspection which naturally includes that property. I have examined this applicant under oath or affirmation and have verified the accuracy of the matters in the affidavit establishing the legal grounds for this Warrant. YOU ARE HEREBY COMMANDED TO INSPECT THE PROPERTY DESCRIBED IN THE ACCOMPANYING AFFIDAVIT. This inspection is authorized to check or reveal the conditions, objects, activities, or circumstances indicated in the accompanying affidavit as a purpose of the inspection program. This Warrant must be served upon the owner or possessor of the property described in the accompanying affidavit. If the owner or possessor is not present on the property at the time of inspection and you have made reasonable but unsuccessful efforts to locate the owner or possessor, you may instead serve it by affixing this Warrant or a copy to the property. THIS WARRANT MAY BE EXECUTED ONLY BETWEEN THE HOURS OF 8:00 A.M. AND 8:00 P.M. AND ONLY WITHIN 24 HOURS AFTER IT WAS ISSUED. IT MUST BE RETURNED WITHIN 48 HOURS AFTER IT WAS ISSUED. Date Issued Time Issued AM PM Signature Deputy CSC Assistant CSC Clerk Of Superior Court Magistrate District Court Judge Superior Court Judge OFFICERS RETURN I certify that this WARRANT was executed on the date and time shown below. Date Of Execution Signature Of Inspecting Official Time Of Execution Name Of Inspecting Official (Type Or Print) AM PM CLERKS ACCEPTANCE This WARRANT has been returned to this office on the date and time shown below. Date Of Return Signature Time Of Return AM PM Deputy CSC Assistant CSC Clerk Of Superior Court IMPORTANT: Attach the Affidavit to the WARRANT if not on reverse side. AOC-CR-914M, Side Two, Rev. 7/2000 2000 Administrative Office of the Courts