File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division County CRIMINAL SUMMONS COMMUNICATING THREATS To the defendant: THE STATE OF NORTH CAROLINA VS. Name And Address Of Defendant I, the undersigned, find that there is probable cause to believe that on or about the date of offense shown and in the county named above, you unlawfully and willfully did threaten to physically injure the person and damage the property of . The threat was communicated to the person by County Of Residence Telephone No. Race Date Of Birth Sex Social Security No. Age and the threat was made in a manner and under circumstances which would cause a reasonable person to believe that the threat was likely to be carried out and the person threatened believed that the threat would be carried out. Drivers License No. & State Name Of Defendant's Employer Offense Code(s) 5328 Offense In Violation Of G.S. 14-277.1 Date Of Offense Complainant (Name, Address Or Department) County Of Residence Telephone No. Names & Addresses Of Witnesses (Including Counties & Telephone Nos.) This act was in violation of the law referred to in this Criminal Summons. This Summons is issued upon information furnished under oath by the complainant listed. You are DIRECTED to appear before the Court at the location, date and time indicated below to answer to the charge. If you fail to appear, you may be held in CONTEMPT OF COURT and imprisoned for up to thirty (30) days or fined up to $500.00, or both. This penalty for failure to appear is in addition to any sentence which may be imposed for the crime charged. Signature Misdemeanor Offense Which Requires Fingerprinting Per Date Issued AOC-CR-140, Rev. 8/97 (Structured Sentencing) 1997 Administrative Office of the Location Of Court Magistrate Deputy CSC Assistant CSC Court Date Court Time Clerk Of Superior Court (Over) American LegalNet, Inc. www.FormsWorkFlow.com AM PM If this Criminal Summons is not served within ninety (90) days, it must be returned to the Clerk of Court in the county in which it was issued with the reason for the failure of service noted thereon. The officer must state all steps taken by the department in attempting to serve the Summons and any information obtained about the whereabouts of the defendant. RETURN OF SERVICE I certify that this Criminal Summons was received and served as follows: Date Received Date Served Date Returned By personally serving this Criminal Summons on the defendant. This Criminal Summons WAS NOT served for the following reason: District Attorney Attorney For Defendant At Time Of Trial Or Plea Appointed Retained Waived PRIOR CONVICTIONS: No./Level: 0 I (0) II (1-4) III (5+) PLEA: VERDICT: guilty 2 3 guilty no contest MISD. CLASS: 1 2 3 guilty no contest guilty MISD. CLASS: 1 not guilty not guilty JUDGMENT: The defendant appeared in open court and freely, voluntarily and understandingly entered the above plea; on the above verdict pay costs and a fine of $ . it is ORDERED that the defendant: be imprisoned for a term of days in the custody of the sheriff. DOC. Pretrial days served. Work release is recommended. is not recommended. [ is ordered. (use form AOC-CR-602)] The Court finds that longer shorter period of probation, than that which is specified in G.S. 15A-1343.2(d), is With defendant's consent, execution of the sentence is suspended and the defendant is placed on unsupervised probation for months, subject to the following conditions: (1) commit no criminal offense in any jurisdiction. (2) possess no firearm, explosive or other deadly weapon listed in G.S. 14-269. (3) remain gainfully and suitably employed or faithfully pursue a course of study or of vocational training, that will equip the defendant for suitable employment, and abide by all rules of the institution. (4) satisfy child support and family obligations, as required by the Court. (5) pay to the Clerk the costs of court and any additional sums shown below. Fine REISSUANCE Signature Dep. CSC Assist. CSC CSC RETURN FOLLOWING REDELIVERY I certify that this Criminal Summons was received and served as follows: Date Received Date Served Attorney's Fee Community Service Fee Other $ $ $ $ *Name(s), address(es), amount(s) & social security number(s) of aggrieved party(ies) to receive restitution: Department Or Agency Of Officer Date Restitution* $ Signature Of Officer Making Return Date Returned 6. complete hours of community service during the days of probation, as directed by the service coordinator, and pay the fee prescribed by G.S. 143B-475.1(b) 7. not be found in or on the premises of the complainant 8. not assault, communicate with or be in the presence of the complainant 9. Other days. By personally serving this Criminal Summons on the defendant. This Criminal Summons WAS NOT served for the following reason: Signature Of Officer Making Return It is ORDERED that this: Department Or Agency Of Officer Judgment is continued upon payment of costs. case be consolidated for judgment with sentence is to run at the expiration of the sentence in COMMITMENT: It is ORDERED that the Clerk deliver two certified copies of this Judgment and Commitment to the sheriff APPEAL ENTRIES and that the sheriff cause the defendant to be retained in custody to serve the sentence imposed or until the defendant shall The defendant, in open court, gives notice of appeal to have complied with the conditions of release pending appeal. the Superior Court. Date Name Of District Court Judge (Type Or Print) Signature Of District Court Judge The current pretrial release order is modified as follows: CERTIFICATION I certify that this Judgment is a true and complete copy of the original which is on file in this case. Date Signature Of District Court Judge Date AOC-CR-140, Side Two, Rev. 8/97 (Structured Sentencing) 1997 Administrative Office of the Courts Date Delivered To Sheriff Signature Deputy CSC Assist. CSC CSC NOTE: If DWI, use AOC-CR-301 (active) or AOC-CR-310 (probation). If active sentence to DOC, use AOC-CR-602. If supervised probation, use AOC-CR-604. American LegalNet, Inc. www.FormsWorkFlow.com