Defendant(s) : ...................................................... File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Court Division THE PEOPLE OF THE STATE OF NEW YORK WARRANT FOR ARREST EMPLOYMENT SECURITY LAW TO THE STATE OF NORTH CAROLINA VS. Name And Address Of Defendant County Of Residence Date Of Birth Sex Social Security No. ORIGINAL 2663 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 make a false statement and representation knowing it to be false, and did knowingly fail to disclose a material fact, in that the GREETINGS: defendant reported to a representative of the Employment Security Commission of North Carolina the "Reported Earnings" YOU, that all for the seven excuses being period which endedeach of "Ending Date" WE COMMAND shown below business and day reporting laid aside, you and on the you attend before shown below when the defendant in fact earned the "Actual Earnings" shown below from the employer , the Honorable at the Court named below. The defendant's false statement and representation and failure to disclose a material fact located at Countywere to obtain and increase a benefit under the Employment Security Law. of Age Drivers License No. & State Name Of Defendant's Current Employer Offense Code(s) To any officer with authority and jurisdiction to execute a warrant for arrest for the offense charged below: in room , on the day of , 20 , at o'clock in the noon, and at any recessed Ending Date or adjourned date, to testify and give evidence as a witness in this action on the part of the Telephone No. Race County Reported Earnings Actual Earnings comply with this subpoena is punishable as a contempt of court and will make you liable to Your failure to $ the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Name And Address Of Employer From Whom Actual Earnings Earned Offense In Violation Of G.S. 96.18(a) Date Of Offense $ Witness, Honorable Court in County, , one of the Justices of the day of , 20 Date Of Arrest & Check Digit No. (As Shown On Fingerprint Card) Complainant (Name, Address Or Department) (Attorney must sign above and type name below) County Of Residence Attorney(s) for Telephone No. Names & Addresses Of Witnesses (Including Counties & Telephone Nos.) This act was in violation of the law referred to in this Warrant. This Warrant is issued upon information furnished under oath by the complainant listed. You are DIRECTED to arrest the defendant and bring the Office and P.O. the charge above. defendant before a judicial official without unnecessary delay to answer Address Signature Misdemeanor Offense Which Requires Fingerprinting Per Date Issued AOC-CR-915M, 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 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Court Time AM PM American LegalNet, Inc. www.USCourtForms.com