File No. STATE OF NORTH CAROLINA CRIMINAL SUMMONS EMPLOYMENT SECURITY LAW THE STATE OF NORTH CAROLINA VS. Name And Address Of Defendant County Of Residence In The General Court Of Justice District Court Division County To the 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 make a false statement and representation knowing it to be false, and did knowingly fail to disclose a material fact, in that you reported to a representative of the Employment Security Commission of North Carolina the "Reported Earnings" shown below for the seven day reporting period which ended on the "Ending Date" shown below when you in fact earned the "Actual Earnings" shown below from the employer named below. Your false statement and representation and failure to disclose a material fact were to obtain and increase a benefit under the Employment Security Law. Telephone No. Ending Date Race Sex Date Of Birth Age ORIGINAL Reported Earnings Actual Earnings Social Security No. $ $ Drivers License No. & State Name Of Defendant's Current Employer Offense Code(s) Offense In Violation Of G.S. Name And Address Of Employer From Whom Actual Earnings Earned 96.18(a) 2663 Date Of Offense Date Of Arrest & Check Digit No. (As Shown On Fingerprint Card) 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 ORDERED to appear before the Court at the location, date and time indicated below to answer to the charge. If you fail to appear, an order for your arrest may be issued and 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 Fingerprint Plan Date Issued AOC-CR-916M, Rev. 8/97 (Structured Sentencing) 1997 Administrative Office of the Courts Location Of Court Magistrate Deputy CSC Assistant CSC Clerk Of Superior Court ORIGINAL Court Date Court Time AM PM American LegalNet, Inc. www.USCourtForms.com District Attorney 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: PLEA: guilty guilty not guilty Attorney For Defendant At Time Of Trial Or Plea VERDICT: no contest no contest Appointed Retained Waived PRIOR CONVICTIONS: No./Level: 0 guilty guilty not guilty I (0) II (1-4) MISD. CLASS: MISD. CLASS: 1 1 2 2 3 3 JUDGMENT: The defendant appeared in open court and freely, voluntarily and understandingly entered the above plea; on the above pay costs and a fine of $ . verdict it is ORDERED that the defendant: be imprisoned for a term of days in the custody of the sheriff. days served. DOC. Pretrial Credit Work release is recommended. is not recommended. [ is ordered. (use form AOC-CR-602)] The Court finds that a longer shorter period of probation, than that which is specified in G.S. 15A-1343.2(d), is necessary. 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 Restitution* Attorney's Fee Community Service Fee Other $ Signature Of Officer Making Return III (5+) $ $ $ $ *Name(s), address(es), amount(s) & social security number(s) of aggrieved party(ies) to receive restitution: Department Or Agency Of Officer REISSUANCE Date Signature Dep. CSC Asst. CSC CSC 6. complete hours of community service during the first service coordinator, and pay the fee prescribed by G.S. 143B-475.1(b) within 7. not be found in or on the premises of the complainant or 8. not assault, communicate with or be in the presence of the complainant or 9. Other: RETURN FOLLOWING REDELIVERY I certify that this Criminal Summons was received and served as follows: Date Received Date Served Date Returned days of probation, as directed by the community 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 APPEAL ENTRIES 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 and that the sheriff cause the defendant to be retained in custody to serve the sentence imposed or until the defendant shall have complied with the conditions of release pending appeal. The defendant, in open court, gives notice of appeal to the Superior Court. The current pretrial release order is modified as follows: Date Name Of District Court Judge (Type Or Print) Signature Of District Court Judge 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-916M, 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.USCourtForms.com