FORM GOV. 1-C, Rev. 10/99 1999 Administrative Office of the Courts STATE OF NORTH CAROLINA CERTIFICATE STATE OF NORTH CAROLINA COUNTY OF I, , Clerk of the Superior Court of County, North Carolina, a court of record, do hereby certify: 1. That is the District Attorney Assistant District Attorney of the Prosecutorial District of North Carolina; and that the attached application for the requisition of has been signed by the above named District Attorney or Assistant District Attorney as aforesaid; 2. That the indictment hereto attached is a true and correct copy of an indictment against , found to be a true bill 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; that the original indictment is on file in my office; and that the said indictment is now pending against the said . In testimony whereof, I have hereunto set my hand and affixed the seal of the said Court, this day of , . Clerk Of Superior Court County, North Carolina (Seal of Court) Address Attach Copy of Indictment to each of the four (4) sets of Application for Requisition at the end of the application by the (Assistant) District Attorney, said copy being certified as shown above.