File No. Name And Address Of JuvenileName Of PetitionerOffense CodeOffense In Violation Of G.S.Physical Address Of Offense, If ApplicableDate Of OffenseTime Of OffenseJuvenile222s Date Of BirthAgeRaceSexG.S. 7B-1501(7), -1801, -1802 þ (NOTE: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ ) þ STATE OF NORTH CAROLINA IN THE MATTER OF þ AM þ PMJUVENILE PETITION (DELINQUENT) I. LARCENY II. POSSESSION 3. þ I. þ LARCENY [G.S. 14-72(a)] (describe property) þ þ þ þ . þ þ II. þ POSSESSION [G.S. 14-71.1] (NOTE: This offense is a felony if Count I is a felony. This offense is a misdemeanor if Count I is a misdemeanor.) III þ NameAddressRelationship/TitleTelephone No.Category Of Offense Felony, Class Misdemeanor, Class American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION Date My Commission ExpiresCounty Where NotarizedSignature Of PetitionerDateCity, State, ZipAddressAgency (if applicable)Title Or Relationship To JuvenileTelephone No.Signature Of Person Authorized To Administer Oaths þ NotarySWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SEAL Deputy CSC Assistant CSC Clerk Of Superior Court MagistrateDate Complaint Received By Juvenile Justice Section Of The Division Of Adult Correction And Juvenile Justice15-DAY EXTENSION OF TIME TO FILE PETITION DateName Of Chief Court CounselorSignature Of Chief Court Counselor Post-Diversion Approval For Filing Of PetitionSignature Of Court CounselorDateDateTimeName Of Court Counselor Giving Telephonic ApprovalName And Title Of Person Receiving Telephonic ApprovalSignature Of Person Receiving Telephonic Approval þ þ AM PM Signature Of Court CounselorDate DECISION OF COURT COUNSELOR REGARDING THE FILING OF THE PETITIONWITNESS(ES) NameAddressTelephone No. American LegalNet, Inc. www.FormsWorkFlow.com