File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division County STATE VERSUS Name Of Defendant Date Of Offense INDICTMENT EMBEZZLEMENT (2718) Offense In Violation of G.S. 14-90 The jurors for the State upon their oath present that on or about the date of offense shown and in the county named above the defendant named above unlawfully, willfully and feloniously did embezzle, fraudulently and knowingly misapply and convert to the defendant's own use, and take and make away with and secrete with the intent to embezzle and fraudulently misapply and convert to the defendant's own use belonging to At the time the defendant was over 16 years of age and was the administrator, agent, bailee, consignee, clerk, employee, executor, guardian, officer, public officer, receiver, servant, trustee, and fiduciary of and in that capacity had been entrusted to receive property described above and in that capacity the defendant had received and taken that property into the defendant's care and possession. (NOTE: For offenses committed on or after December 1, 1997, check this option if applicable.) The value of the items described above was $100,000.00 or more. Signature Of Prosecutor WITNESSES The Witnesses marked "X" were sworn by the undersigned Foreman of the Grand Jury and, after hearing testimony, this Bill was found to be: A TRUE BILL by twelve or more grand jurors, and I the undersigned Foreman of the Grand Jury, attest the concurrence of twelve or more grand jurors in this Bill of Indictment. NOT A TRUE BILL. Date Signature Of Grand Jury Foreman AOC-CR-130, Rev. 12/97 1997 Administrative Office of the Courts American LegalNet, Inc. www.USCourtForms.com