File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division District County STATE VERSUS WORKSHEET PRIOR RECORD LEVEL FOR FELONY SENTENCING AND PRIOR CONVICTION LEVEL FOR MISDEMEANOR SENTENCING Name And Address Of Defendant Social Security No. Race SID No. Sex (STRUCTURED SENTENCING) (For Offenses Committed On Or After Dec. 1, 2009) DOB G.S. 15A-1340.14, 15A-1340.21 I. SCORING PRIOR RECORD/FELONY SENTENCING NUMBER TYPE FACTORS Prior Felony Class A Conviction X10 Prior Felony Class B1 Conviction X 9 Prior Felony Class B2 or C or D Conviction X 6 Prior Felony Class E or F or G Conviction X 4 Prior Felony Class H or I Conviction X 2 Prior Class A1 or 1 Misdemeanor Conviction (see note on reverse) POINTS X 1 SUBTOTAL Defendant's Current Charge(s): If all the elements of the present offense are included in any prior offense whether or not the prior offenses were used in determining prior record level. +1 If the offense was committed: (a) while on supervised or unsupervised probation, parole, or post-release supervision; or (b) while serving a sentence of imprisonment; or (c) while on escape. +1 TOTAL II. CLASSIFYING PRIOR RECORD/CONVICTION LEVEL MISDEMEANOR NOTE: If sentencing for a misdemeanor, total the number of prior conviction(s) listed on the reverse and select the corresponding prior conviction level. No. Of Prior Convictions 0 1-4 5+ Level I II III PRIOR CONVICTION LEVEL The Court has determined the number of prior convictions to be and the level to be as shown above. In making this determination, the Court has relied upon the State's evidence of the defendant's prior convictions from a computer printout of DCI-CCH. FELONY NOTE: If sentencing for a felony, locate the prior record level which corresponds to the total points determined in Section I above. Points Level I 0-1 PRIOR II 2-5 RECORD III 6-9 IV LEVEL 10 - 13 V 14 - 17 VI 18+ The Court finds the prior convictions, prior record points and the prior record level of the defendant to be as shown herein. In making this determination, the Court has relied upon the State's evidence of the defendant's prior convictions from a computer printout of DCI-CCH. In finding a prior record level point under G.S. 15A-1340.14(b)(7), the Court has relied on the jury's determination of this issue beyond a reasonable doubt or the defendant's admission to this issue. The Court finds that all of the elements of the present offense are included in a prior offense. For each out-of-state conviction listed in Section V on the reverse, the Court finds by a preponderance of the evidence that the offense is substantially similar to a North Carolina offense and that the North Carolina classification assigned to this offense in Section V is correct. The Court finds that the State and the defendant have stipulated in open court to the prior convictions, points and record level. Date Name Of Presiding Judge (Type Or Print) AOC-CR-600, Rev. 4/11 © 2011 Administrative Office of the Courts Signature Of Presiding Judge (Over) American LegalNet, Inc. www.FormsWorkFlow.com III. STIPULATION The prosecutor and defense counsel, or the defendant, if not represented by counsel, stipulate to the information set out in Sections I and V of this form, and agree with the defendant's prior record level or prior conviction level as set out in Section II based on the information herein. Date Signature Of Prosecutor Date Signature Of Defense Counsel Or Defendant IV. DNA CERTIFICATION (For Offenses Committed On Or After Feb. 1, 2011) A review of the case record (the form required by G.S. 15A-266.3A(c)) and the records of the State Bureau of Investigation (the DCI-CCH rap sheet) indicates that (check one): 1. The defendant is NOT required to provide a DNA sample for this conviction because (i) the offense is not covered by G.S. 15A-266.4 or (ii) a sample of the defendant's DNA has previously been obtained and the defendant's DNA record is currently stored in the State DNA database. 2. The defendant IS required to provide a DNA sample for this conviction because (i) the offense is covered by G.S. 15A-266.4 and (ii) a sample of the defendant's DNA has not previously been obtained and the defendant's DNA record has not previously been stored in the State DNA Database, or if previously obtained and stored, the defendant's DNA sample and record have been expunged. Name Of Prosecutor (Type Or Print) Date Signature Of Prosecutor V. PRIOR CONVICTION NOTE: Federal law precludes making computer printout of DCI-CCH (rap sheet) part of permanent public court record. NOTE: The only misdemeanor offenses under Chapter 20 that are assigned points for determining prior record level for felony sentencing are misdemeanor death by vehicle [G.S. 20-141.4(a2)] and, for sentencing for felony offenses committed on or after December 1, 1997, impaired driving [G.S. 20-138.1] and commercial impaired driving [G.S. 20-138.2]. First Degree Rape and First Degree Sexual Offense convictions prior to October 1, 1994, are Class B1 convictions. Source Code Offenses File No. Date Of Conviction County (Name of State if not NC) Class See AOC-CR-600A for additional prior convictions. Source Code: 1 - DCI 2 - NCIC 3 - AOC/Local 4 - AOC/Statewide AOC-CR-600, Side Two, Rev. 4/11 © 2011 Administrative Office of the Courts 5 - ID Bureau 6 - Other Date Prepared: Prepared By: American LegalNet, Inc. www.FormsWorkFlow.com