File No. STATE OF NORTH CAROLINA WARRANT FOR ARREST FOR FUGITIVE County In The General Court Of Justice District Court Division Crime(s) In Demanding State To any officer with authority and jurisdiction to execute a warrant for arrest: I, the undersigned, find that there is probable cause to believe that on or about the date of offense shown and in the demanding state and county named above the crime named above was committed and the defendant named above is now in the State of North Carolina and has been charged with the commission of that crime and has fled from justice. has been convicted of that crime and has escaped from confinement. has broken the terms of his/her bail, probation and parole. This Warrant is issued pursuant to Section 15A-733 of the North Carolina General Statutes upon information furnished under oath by the complainant listed. You are DIRECTED to arrest the defendant and bring the defendant before a judicial official without unnecessary delay to answer the charge above. Date Of Offense Name Of Demanding State And County Of Offense THE STATE OF NORTH CAROLINA VS. Name And Address Of Defendant Race Social Security No. Sex Date Of Birth Age Drivers License No. & State Name Of Defendant's Employer Offense Code(s) Arrest Under G.S. 9901 15A-733 Date Of Arrest & Check Digit No. (As Shown On Fingerprint Card) Arresting Officer (Name, Department, Phone No.) Date Issued Signature Location Of Court Court Date Court Time Magistrate District Court Judge Superior Court Judge AM PM AOC-CR-910M, Rev. 4/11 © 2011 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com If this Warrant For Arrest is not served within one hundred and eighty (180) 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 execute the Warrant and any information obtained about the whereabouts of the defendant. RETURN OF SERVICE I certify that this Warrant was received and served as follows: Date Received Date Served Time Served AM PM Date Returned By arresting the defendant and bringing the defendant before: Name Of Judicial Official This Warrant WAS NOT served for the following reason: Signature Of Officer Making Return Department Or Agency Of Officer RETURN FOLLOWING REDELIVERY I certify that this Warrant was received and served as follows: Date Received Date Served Time Served AM PM Date Returned By arresting the defendant and bringing the defendant before: Name Of Judicial Official This Warrant WAS NOT served for the following reason: Signature Of Officer Making Return Department Or Agency Of Officer American LegalNet, Inc. www.FormsWorkFlow.com AOC-CR-910M, Side Two, Rev. 4/11 © 2011 Administrative Office of the Courts