STATE OF NORTH CAROLINA County Name And Address Of Defendant File No. In The General Court Of Justice District Superior Court Division STATE VERSUS INFORMATION Race Sex Date Of Birth G.S. 15A-644 Offense(s) Date Of Offense OR Date Range Of Offense G.S. No. CL. I. II. III. I. I, the undersigned prosecutor, upon information and belief allege that on or about the date(s) of offense shown above and in the county indicated above, the defendant named above unlawfully, willfully and feloniously did II. I, the undersigned prosecutor, upon information and belief allege that on or about the date(s) of offense shown above and in the county indicated above, the defendant named above unlawfully, willfully and feloniously did (Over) AOC-CR-123, Rev. 1/13 � 2013 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com III. I, the undersigned prosecutor, upon information and belief allege that on or about the date(s) of offense shown above and in the county indicated above, the defendant named above unlawfully, willfully and feloniously did Signature Of Prosecutor WAIVER I, the undersigned defendant, waive the finding and return of a Bill of Indictment into Court and agree that the case may be tried upon the above information. Date Signature Of Defendant Signature Of Attorney For Defendant AOC-CR-123, Side Two, Rev. 1/13 � 2013 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com