STATE OF NORTH CAROLINA Vs. 1 2 3 File No. JURY BACK ROW Film No. 4 5 6 7 8 9 10 11 12 CHALLENGES For Cause State Or Plaintiff Defendant FRONT ROW I certify that in the above-numbered case the persons whose names appear above were called as jurors, that those whose names are marked through were excused, and that those whose names are not marked through were empanelled to serve as jurors. Date Signature Dep. CSC Asst. CSC CSC AOC-G-111, Rev. 2/12 © 2012 Administrative Office of the Court American LegalNet, Inc. www.FormsWorkFlow.com