FORM GOV. 1, Rev. 10/99 1999 Administrative Office of the Courts State of North Carolina APPLICATION FOR REQUISITION (NORMAL) TO THE GOVERNOR OF THE STATE OF NORTH CAROLINA, : THE UNDERSIGNED, DISTRICT ATTORNEY ASSISTANT DISTRICT ATTORNEY of Prosecutorial District of North Carolina, (address) , hereby makes this verified applicationfor the requisition of , the accused, charged with the CRIME of , in the COUNTY of .IN SUPPORT OF SUCH APPLICATION, YOUR PETITIONER HEREBY SHOWS THE FOLLOWING FACTS: 1. That the FULL NAME of the person for whom requisition is asked is . 2. That in his/her opinion, the ends of public justice require that the subject be arrested and brought back to the State of North Carolina for trial at public expense. 3. That he/she believes that he/she has sufficient evidence to secure the conviction of the subject. 4. That the name of the AGENT - proposed to receive the subject from the proper authorities of the State of and bring said subject to the State of North Carolina for trial is (are) (name and title, name female agent if accused is female) and/or Authorized Agent(s); AND that the person - named as AGENT - is (are) a proper person - and that he/she (they) has (have) no private interest in the arrest and conviction of the subject. 5a. That, according to information and belief, there HAS NOT BEEN a former request for the requisition of the subject, growing out of the same transaction herein alleged. 5b. That, there HAS BEEN a former request for the requisition of the subject, growing out of the same transaction herein alleged: (date of prior application) (explanation of reasons for present request for requisition) . 6. That the subject is now under ARREST in the State of , and in the custody of (name and address) , and the grounds for such belief is as follows: , (and has been released on bail from this custody, and is presently residing at (home or business address) ). And the undersigned is further informed and believes that the police authorities in the said city and state are willing to surrender said accused to the proper authorities of the State of North Carolina. 7. That this Application is not made for the purpose of serving the accused with civil process, or for the purpose of collecting a debt or enforcing a private claim, or for any private purpose whatever, and that if the requisition applied for be granted, the criminal proceedings will not be used for any of said objects. >>>> 2FORM GOV. 1, Rev. 10/99 PAGE TWO 1999 Administrative Office of the Courts APPLICATION FOR REQUISITION (NORMAL) 8. That the extradition of the subject to the State of North Carolina is hereby requested for the purpose of trial on the charge of committing the CRIME of , as defined in North Carolina GENERAL STATUTES (code-section) as set forth in: a. WARRANT, heretofore issued against him/her accompanied by COMPLAINT (Affidavit to the facts thereof by a person having actual knowledge thereof), as per hereto attached. b. INDICTMENT, heretofore found against subject on the day of , by the Grand Jurors for the State of North Carolina in and for the County of , attending the Superior Court of the said county, which Indictment is now pending against the subject, and of which is hereto attached. 9a. That the alleged Crime was committed in (place-date) ; and That said subject was personally and physically present in , North Carolina, at the time of the commission of the alleged crime, and thereafter the subject fled from the State of North Carolina to avoid arrest and prosecution. 9b. That said subject, insofar as is known, WAS NOT IN THE STATE OF NORTH CAROLINA at the time of the commission of the crime of which he/she is charged, and has not since that time fled from this State, but that this requisition is sought under Section 6 of the Uniform Extradition Act, G.S. 15A-726, which your Applicant is informed has been adopted by the State of ; and that the subject, while in the State of , committed an Act, to wit , which intentionally resulted in the commission of a crime, to wit , in the State of North Carolina. 10a. That this Application was made as soon as the subject could be located. 10b. That there has been a considerable lapse of time since the date of the alleged crime, explanation of which is as follows: . 11a. That this Application is verified by the above named District Attorney or Assistant District Attorney as aforesaid, and is accompanied by certified copies of the WARRANT heretofore issued against the said subject by , a duly appointed, qualified, and acting Magistrate, Judge, and COMPLAINT, and other certifications by proper authorities that the Signers of the Documents are qualified. 11b. That this Application is verified by the above named District Attorney or Assistant District Attorney as aforesaid, and is accompanied by certified copies of the INDICTMENT heretofore found against the said subject by the Grand Jurors in the State of North Carolina in and for the County of , attending the Superior Court of said county, which indictment is now pending against the subject; and other certifications by proper authorities that the Signers of the Documents are qualified.>>>> 3FORM GOV. 1, Rev. 10/99 1999 Administrative Office of the Courts PAGE THREE APPLICATION FOR REQUISITION (NORMAL) 12. , being duly sworn, deposes and says: I am the District Attorney Assistant District Attorney of the County of in the State of North Carolina. I have read the foregoing application for the return of the named accused to the State of North Carolina, and the facts therein stated are true according to the best of my knowledge, information, and belief. (Assistant) District Attorney SEAL Sworn and subscribed to before me, this the day of , . Clerk, Superior Court Or Proper Official County And Address (1) This Application may be used for all persons accused with exception of: Violators of Conditions of Probation, Parole, or Conditional Releases; Escapees or Bail Violators after confinement. (2) Select the (a) or (b) which applies in your case, as follows: 5a. b.; 8a. b.; 9a. b.; 10a. b.; 11a. b. Leave what you do not use vacant.(3) Attach Copy of applicable Statute. (4) Attach identification: Fingerprints and/or photograph.