STATE OF NORTH CAROLINA County Civil: Criminal Name Of Defendant Name Of Witness (Detainee) Race Offender ID (if any) Name Of Agency In Whose Custody Witness Confined Or Committed N.C. DAC Sheriff of County Sex Date Of Birth File No. In The General Court Of Justice Superior Court Division District Plaintiff: STATE VERSUS APPLICATION AND WRIT OF HABEAS CORPUS AD TESTIFICANDUM Nature Of Proceeding G.S. 17-41 through 17-46 Division Of Juvenile Justice NOTE: Use this form to obtain the presence of a witness in a civil or criminal case. Use the "Prosecutor's Request For Temporary Custody Of Defendant For Trial," AOC-CR-900, or the "Application And Writ Of Habeas Corpus Ad Prosequendum," AOC-CR-223, to obtain the presence of a defendant for the trial of criminal charges pending against the defendant. APPLICATION The undersigned party to this proceeding has been advised by counsel and verily believes that the detainee named above is a witness whose testimony is material and necessary to the party in the trial or hearing of this proceeding. The detainee is detained in a jail, prison or detention center in the custody of the agency named above, and the undersigned requests that the court issue a Writ of Habeas Corpus ad Testificandum to bring the detainee before the court to be examined as a witness on behalf of the party. Name Of Party For Whom Witness To Testify: SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Signature Of Person Authorized To Administer Oaths Date Signature Name (Type Or Print) Deputy CSC Notary Assistant CSC Clerk Of Superior Court Magistrate Date My Commission Expires County Where Notarized Party Attorney For Party SEAL WRIT To The Agency Named Above: The witness named above is confined or committed in your custody. Upon the above verified application, you are ORDERED to deliver the detainee to the custody of the person named below so that the detainee may be brought before this Court to be examined as a witness in this proceeding. TO: The Sheriff Of This County Other You are ORDERED to serve this Writ upon the agency named above, to take the detainee into custody and bring the detainee before this Court on the date and at the time and place shown below and, when the trial of this case has been completed and the detainee is released by the Court, to return the detainee to the custody of that agency. Court Date Location Of Court Court Time AM PM Date Signature Name (Type Or Print) District Court Judge Superior Court Judge Clerk Of Superior Court Magistrate Original-Sheriff AOC-G-112, Rev. 6/12 � 2012 Administrative Office of the Courts Copy-Applicant (Over) Copy-File American LegalNet, Inc. www.FormsWorkFlow.com RETURN OF SERVICE I certify that this Writ was received and served as follows. Date Writ Received Name Of Person Served Date Detainee Received From Custodian Date Detainee Returned To Custodian Date Writ Served On Custodian Date Of Return Of Service Signature Of Person Making Return Of Service Deputy Sheriff Other Fees And Expenses Of Bringing Detainee To Court* $ Fees And Expenses For Carrying Detainee Back To Custodian Paid Due Paid Due $ *NOTE: G.S. 17-44 provides "The service of the writ shall not be complete, however, unless the applicant for the same tenders to the person in whose custody the prisoner may be, if such person is a sheriff, coroner, or marshal, the fees and expenses allowed by law for bringing such prisoner, nor unless he also gives bond, with sufficient security, to such sheriff, coroner, or marshal, as the case may be, conditioned that such applicant will pay the charges of carrying back such prisoner." G.S. 7A-311(a)(5) provides "(a) In a civil action or special proceeding, except for actions brought under Chapter 50B of the General Statutes, the following fees and commissions shall be assessed, collected, and remitted to the county:... (5) For necessary transportation of individuals to or from State institutions or another state, the same mileage and subsistence allowances as are provided for State employees." AOC-G-112, Side Two, Rev. 6/12 � 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com