File No. STATE OF NORTH CAROLINA In The General Court Of Justice County District Court Division IN THE MATTER OF: Name And Address Of Respondent (Including Zip Code) AUTOMATIC INVOLUNTARY COMMITMENT OF DEFENDANT FOUND NOT GUILTY BY REASON OF INSANITY G.S. 15A-1321; 122C-268.1 FINDINGS AND COMMITMENT The respondent has been charged in File No. with a criminal offense in the above named county and has been found not guilty by reason of insanity. Therefore, the Court ORDERS the respondent committed to the State 24-hour facility named below. The Court also ORDERS the law enforcement agency named below to take the respondent into custody and transport the respondent directly to the State 24-hour facility named below for commitment. Name Of State 24-Hour Facility Date Signature Of Judge Name Of Law Enforcement Agency To Transport Name Of Judge (Type Or Print) RETURN OF SERVICE I certify that this Order was received and served as follows: I took respondent into custody and transported respondent directly to and placed respondent in the custody of the facility named below. Date Respondent Taken Into Custody Date Delivered Name Of State 24-Hour Facility I did not carry out the order for the following reason: Date Order Received Signature Of Law Enforcement Officer Date Of Return Name Of Transporting Agency AOC-SP-910M, Rev. 7/98 1998 Administrative Office of the Courts