File No. Law Enforcement Case No. LID No. SID No. FBI No. CRIMINAL SUMMONS MISDEMEANOR WORTHLESS CHECK THE STATE OF NORTH CAROLINA VS. I. Simple Or Subsequent Offense II. Fourth STATE OF NORTH CAROLINA County In The General Court Of Justice District Court Division Name And Address Of Defendant Race Sex Date Of Birth Age 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 the defendant named above unlawfully and willfully did draw, make, utter and issue and deliver to a check drawn upon (name of financial institution) of (city and state of financial institution) , for the payment of $ in money. The check was made payable to and was dated . The defendant knew at the time he/she: (check one) did not have sufficient funds on deposit or credit with the bank with which to pay the check on presentation in violation of G.S. 14-107(a)(1). had previously presented the check or draft for the payment of money or its equivalent in violation of G.S. 14-107(a)(2). Social Security No./Tax ID No. Name Of Defendant's Employer Offense Code(s) Drivers License No. & State $ Processing Fee [G.S. 25-3-506] (not to exceed $25) Bank Service Charge Amount Of Check Total Restitution Offense In Violation Of G.S. I. 2666 Date Of Offense Amount Of Check II. 2656 14-107 The defendant was convicted three times previously of the crime of writing a worthless check as follows: FOURTH OR SUBSEQUENT OFFENSE. [G.S. 14-107(d)(1)] Date $ $ $ Complainant (Name, Address Or Department) $ District Superior District Superior District Superior Court County 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. Arrest and/or contempt for failure to appear is in addition to any sentence which may be imposed for the crime charged. The undersigned finds the following cause to set a court date more than one month from the issue of this summons: . Signature Date Issued Magistrate Assistant CSC Deputy CSC Clerk Of Superior Court (Over) Location Of Court Court Date Court Time AM PM AOC-CR-115, Rev. 2/15 � 2015 Administrative Office of the Courts NOTE: Do not use this form if the amount of the check is more than $2,000.00. American LegalNet, Inc. www.FormsWorkFlow.com If this Criminal Summons is not served within ninety (90) days or by the date District Attorney the defendant is directed to appear, whichever is earlier, 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. I certify that this Criminal Summons was received and served as follows: Date Received Date Served Time Served RETURN OF SERVICE PLEA: guilty no contest not guilty Waived Not Indigent Denied Attorney For Defendant Appointed Retained guilty not guilty PRIOR CONVICTIONS: No./Level: 0 I (0) II (1-4) III (5+) VERDICT: M.CL. 1 2 3 Signature Of Officer Making Return Department Or Agency Of Officer JUDGMENT: The defendant appeared in open court and freely, voluntarily and understandingly entered the above plea; on the above verdict it is ORDERED that the defendant: pay costs and a fine of $ . be imprisoned for a term of days in the custody of the sheriff. MCP. DA C.* Pretrial credit days served. By personally serving this Criminal Summons on the defendant. Work release is recommended. is not recommended. [ is ordered. (use form AOC-CR-602)] This Criminal Summons WAS NOT served for the following The Court finds that a longer shorter period of probation, than that which is specified in G.S. 15A-1343.2(d), is necessary. reason: 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. AM PM Date Returned Name Of Officer (Type Or Print) Fine Restitution** Attorney's Fee Community Service Fee Other $ $ $ $ $ Date REDELIVERY/REISSUANCE Signature **Name(s), address(es), and amount(s) for aggrieved party(ies) to receive restitution: NOTE TO CLERK: Record SSN or Tax ID No. of aggrieved party(ies) on AOC-CR-382, "Certification Of Identity (Victims' Restitution)/Certification Of Identity (Witness Attendance)." The clerk finds moreaboveone month the following cause to set a court date than from reissue: Dep. CSC Assist. CSC CSC hours of community service during the first days of probation, as directed by the 6. complete judicial services coordinator, and pay the fee prescribed by G.S. 143B-708 within days. 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. refrain from maintaining a checking account or making or uttering a check for three years. 10. Other: . . Date Received RETURN FOLLOWING REDELIVERY/REISSUANCE I certify that this Criminal Summons was received and served as follows: Date Served Time Served By personally serving this Criminal Summons on the defendant. This Criminal Summons WAS NOT served for the following reason: Signature Of Officer Making Return Department Or Agency Of Officer Name Of Officer (Type Or Print) AM PM Date Returned It is ORDERED that this: defendant, TheDistrict Courtin open court, gives notice of appeal to the Superior Court. The current pretrial release order is modified as follows: APPEAL ENTRIES Date . . 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. Name Of District Court